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PubMed1995

[Results of follow-up of surgical treatment of complicated acetabulum fractures with extended approaches].

Extended approaches are indicated for complex acetabular fractures. The advantage of extended approaches is the simultaneous exposure of both columns of the acetabulum; disadvantages are the wide exposure of the soft tissue and a high rate of heterotopic ossification. Muscle weakness and necrosis of the muscle have been described. Although there is good exposure with an extended approach, the indication for it is restricted. Between 1972 and 1993, 688 patients with acetabular fractures were treated at the Trauma Department of the Hannover Medical School; 322 had open reduction and internal fixation. Thirty-five patients (10%) were treated with an extended approach. In a retrospective study of 24 patients treated with an extended approach between 1985 and 1993, perioperative data, long-term clinical outcome and radiological outcome were investigated. The aim of the study was to compare the outcome of two groups treated using either the classical extended iliofemoral approach or the Maryland modification. Eleven patients were treated with the extended iliofemoral approach, 13 with the Maryland approach. There were no significant differences in age, type of accident, fracture classification, time to operation, time of operation and blood loss. The postoperative X-ray was anatomic or nearly anatomic in 22 cases; 2 patients had a dislocation of more than 2 mm. The main complications were hematomas and seromas. In both groups we found one thrombosis and one nerve injury with partial recovery. Twenty patients were followed up at least 2 years after trauma, 8 after extended iliofemoral approach and 12 after Maryland approach.(ABSTRACT TRUNCATED AT 250 WORDS)

Acetabulum↗

PubMed2005

Defining the learning curve for percutaneous nephrolithotomy.

PURPOSE: To define the learning curve for percutaneous nephrolithotomy (PCNL) using three potential surrogate markers of surgical expertise. MATERIALS AND METHODS: The learning curve of an endourologist with no previous experience at performing solo PCNL was studied. Three putative parameters of expertise were reviewed, namely, operating time, fluoroscopic screening time, and radiation dose. Operations were analyzed in cohorts of 15 to determine when a plateau was reached for all three variables. Comparison was then made with the results of a surgeon who had performed more than 1600 PCNLs. Stone type and stone clearance rate were also noted. RESULTS: The mean operating time of the novice surgeon fell to a plateau of 92 minutes after 60 cases, but screening time and radiation dose did not plateau until case 115, when values of 231 seconds and 406 cGy/cm2 were recorded, respectively. The senior surgeon had a mean operating time of 98 minutes and screening parameters equivalent to those of the novice surgeon after 115 cases. The complexity of the stones tackled grew with increasing experience, although stone-free rates remained constant. CONCLUSIONS: This study of the learning curve of a single surgeon suggests that competence at performing PCNL is reached after 60 cases and excellence after 115. Radiation parameters are a valuable tool in the assessment of operative competence.

Clinical Competence↗

PubMed2006

[A study of 4,031 patients of transurethral resection of the prostate performed by one surgeon: learning curve, surgical results and postoperative complications].

A total of 4,031 patients who underwent transurethral resection of the prostate (TURP) performed by one surgeon between May 1979 and December 2003 were retrospectively examined to determine the improvement of the surgeon's skill in performing TURP assessed by using a learning curve, surgical results and postoperative complications. Analysis using the learning curve, which displayed the relationship between the number of TURP procedures and the speed of resection (i.e., the weight of tissue resected divided by the operation time), revealed that 81 operations were needed before the surgeon's skill reached a plateau in performing TURP. The means +/- standard deviations of the weight of tissue resected, operation time and speed of resection were 17.0 +/- 14.6 g, 21.0 +/- 13.5 minutes, 0.80 +/- 0.32 g/minutes, respectively. As the number of TURP procedures increased and the level of skill improved, the operation time was significantly reduced and the speed of resection was significantly increased. The incidences of postoperative complications were 2.4% for blood transfusion, 0.3% for the TURP syndrome, 1.5% for hemostatic procedures, 2.8% for bladder neck contracture, and 1.0% for urethral stricture. The incidences of transfusion and the TURP syndrome decreased as the surgeon's skill improved. The mortality rate was 0.1%.

Aged↗

PubMed2000

Rebleeding, secondary ischemia, and timing of operation in patients with subarachnoid hemorrhage.

OBJECTIVE: To assess the time course of secondary ischemia and first rebleeding and the relation between the timing of operation and the time course of secondary ischemia in a consecutive series of patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS: Life table methods were used to assess the daily rates of ischemia and of rebleeding on day 0, day 1 to 3, day 4 to 10, day 11 to 14, and day 15 to 21. The authors compared the time course of secondary ischemia between patients operated within 4 days of SAH and those operated after 10 days. RESULTS: Of 346 patients included, 220 were operated, 131 within 4 days and 74 after 10 days. The rebleed rate was highest on the day of the initial hemorrhage, then diminished, and increased slightly again during the second week. The rate of secondary ischemia was highest on day 4, diminished after day 10, but peaked again from day 14 to 18 for patients who were operated later than 10 days after aneurysmal rupture. The peak rate of ischemia was much higher after early than after late operation. Although patients with early operation were in a better clinical condition on admission, with a relatively low risk of secondary ischemia, the overall rate of secondary ischemia was as high as in patients with delayed operation. From day 11 to 21 the rebleed rate was higher than the rate of secondary ischemia. CONCLUSIONS: These results indicate that operation is a risk factor for ischemia, especially when performed early. If operation is postponed, it should be planned soon after day 10, because of the relatively high rebleed rate from day 11 to 21.

Brain Ischemia↗

PubMed2005

Long term complications in single and dual chamber pacing are influenced by surgical experience and patient morbidity.

OBJECTIVE: To determine how short and long term complication rates after pacemaker implantation are influenced by patient morbidity, operator experience, and choice of pacing system. DESIGN: Retrospective analysis of 1884 patients who received VVI (n = 610), VDD (n = 371), or DDD devices (n = 903) between 1990 and 2001. Follow up period was 64 (34) months. The influence of age, sex, coronary artery disease, myocardial infarction, reduced left ventricular (LV) function, right ventricular (RV) dilatation, atrial fibrillation, device type, and operator experience on operation time and complication rate were analysed. RESULTS: Operation time was prolonged in patients with coronary artery disease, inferior myocardial infarction, reduced LV function, and RV dilatation. Implantation of DDD pacemakers prolonged operation time, particularly among operators with a low or medium level of experience. The overall complication rate was 4.5%. Sixty seven per cent of these complications occurred within the first three months. Complication rate was increased by age, reduced LV function, and RV dilatation. Implantation of DDD systems led to a higher complication rate (6.3%) than implantation of VVI (2.6%) or VDD pacemakers (3.2%). These differences were present only among operators with a low or medium level of experience. CONCLUSIONS: Operation time and complication rate increased with age, impaired LV function, and RV dilatation. Complication rates were higher with DDD than with VVI or VDD implantation and were excessive among inexperienced but not experienced operators.

Age Factors↗

PubMed2003

Risk of elevated creatine kinase and myoglobulinemia due to incised muscles in patients who underwent urological surgery.

PURPOSE: We clarified the risk of elevated creatine kinase (CK) and myoglobulinemia during incised muscle urological operations. MATERIALS AND METHODS: We retrospectively reviewed 58 consecutive cases of radical nephrectomy with muscle incision and 89 consecutive radical prostatectomies or radical cystectomies without muscle incision. Operations with or without muscle incision were divided into 2 groups depending on operative time (200 minutes or less and 201 to 400). Increases in CK and myoglobin were compared between the 2 groups, and between muscle incision and no muscle incision at each operative time. RESULTS: CK and myoglobin were proportionally increased according to operative time in operations without muscle incision but not in muscle incision operations, in which high CK and myoglobin were seen even with short operative times. CK and myoglobin were more increased in muscle incision operations than in those without incision with significance at each operative time. However, maximum CK and myoglobin were 2,220 IU/L and 3,600 ng/ml, respectively, in muscle incision operations. CONCLUSIONS: Even with short operative times surgeries with muscle incision are associated with a marked increase in CK and myoglobulinemia. However, CK and myoglobin are not sufficiently high for rhabdomyolysis with acute renal failure to develop.

Creatine Kinase↗

PubMedDate not supplied

[Prostatic electrovaporization, a new treatment for prostatic hyperplasia].

TUR remains the choice technique for the surgical management of bph BUT, though effective, is not entirely free of morbidity. Over the last few years, new techniques have been developed trying to decrease morbidity, of which laser procedures are the most successful ones. We report here the prostate electrovaporization technique and our preliminary results in 75 patients seen over a 5-month period. The efficacy of the system is evaluated using the IPSS score and peak flow values; safety was assessed through the complications arisen, vesical catheter time and operating time. Mean hospital stay was 2 days, length of operation 32 minutes and post-operative vesical catheter time 48 hs; at 3 months, mean peak flow was 19.2 ml/seg and mean IPSS 7. Based en our preliminary results, quick convalescence, decreased cost and casiness of the technique, we consider prostate electrovaporization a likely alternative to conventional TUR, although further longer-term studies are warranted in order to evaluate the histological changes caused by this procedure on the prostate tissue.

Aged↗

PubMed2004

[Comparative study of tension-free vaginal tape and fascia lata for stress urinary incontinence].

OBJECTIVE: To compare the efficacy of surgically managing stress urinary incontinence (SUI) with tension-free vaginal tape (TVT) and autologous fascia lata pubovaginal sling (Lata). METHODS: Sixty-seven patients suffering from SUI entered this prospective study. The patients were divided into two groups randomly, 48 in TVT group and 19 in Lata group. The average follow-up time post-operation was 20 months in TVT group and 37 months in Lata group. RESULTS: The operating time was (27 +/- 5) min in TVT and (125 +/- 13) min in Lata. The volume of blood loss during surgery was: (27 +/- 6) ml in TVT and (67 +/- 11) ml in Lata. The post-operative recovery period in the hospital was: TVT, 1.8 days and Lata, 7.2 days. The differences between the two groups for these three parameters were statistically significant (P < 0.01). The 3-month cure rate post-operations was 94% (45/48) for TVT and 95% (18/19) for Lata. The surgical complications included 1 case of vesical perforation and 2 cases of overactive bladder in TVT group. CONCLUSIONS: TVT and Lata are both effective and safe surgical treatments for stress urinary incontinence. TVT has the benefits of being minimally invasive with a shorter operating time and a quicker recovery for the patients. A disadvantage is that the tape used in TVT is expensive, making the operation rather costly. Lata on the other hand is cheaper and may result in fewer complications, but the operation is not as easy for the patient.

Aged↗

PubMed2002

Laparoscopic Roux-en-Y gastric bypass: defining the learning curve.

BACKGROUND: Increasing numbers of laparoscopic surgeons are performing laparoscopic Roux-en-Y gastric bypass (LGB). Our aim was to determine the length of the learning curve for a skilled laparoscopic surgeon. METHODS: The study population consisted of the first 225 consecutive LGB procedures attempted by one laparoscopic surgeon (HJS). Outcome parameters included mortality, morbidity, operative time, and conversion to an open procedure. RESULTS: Average operative time decreased from 189 min (first 75 patients) to 125 minutes (last 75 patients). Most of the improvement in operative time occurred over the first 75 patients. The perioperative complication rate decreased from 32% (first 75 patients) to 15% (second and third groups of 75 patients). Complication rates did not significantly decrease after the first 75 patients. Low mortality and conversion rates were achieved early in the series. CONCLUSION: Low mortality rates and low conversion rates can be achieved early in the learning curve for LGB. Complication rates plateau after approximately 75 LGBs, and operative times decrease substantially over the initial 75 cases. Operative times continue to decrease at a slower rate beyond 75 cases.

Adult↗

PubMed1989

Pediatric liver transplantation: a 3-year experience.

From September 1, 1984 to March 1, 1988, 201 patients were evaluated for liver transplantation. Ninety-one orthotopic liver transplants were performed on 80 children ranging in age from 3 months to 15 years. The average waiting time for a transplant was 5 months, with children less than 10 kg in weight waiting a disproportionately long time. The average operative time was 10.6 hours and the average blood product replacement was 2.7 blood volumes. There was a steady improvement in both operative time and blood loss from 1985 to 1987. The overall hepatic arterial thrombosis rate was 9%; complex reconstructions having a thrombosis rate of 39%, and end-to-end anastomoses having a thrombosis rate of 1.4%. The average hospital stay was 37 days, and the major causes of postoperative morbidity and mortality were rejection (75%), infection (50%), and diarrhea (76%). The 1- and 3-year survival rates were 75% and 73%, respectively. Children with a successful transplant returned to home and school. After transplantation, 60% of the children exhibited catch-up growth and 88% have normal liver function. Pediatric liver transplantation is an effective modality in the treatment of children with terminal liver disease. Increased pediatric organ donation and the investigation of new operative techniques and types of preservation are necessary to meet the needs of an expanding recipient pool.

Adolescent↗

PubMed2005

Characterization of subwavelength elastic cylinders with the decomposition of the time-reversal operator: theory and experiment.

The decomposition of the time-reversal operator provides information on the scattering medium. It has been shown [Chambers and Gautesen, J. Acoust. Soc. Am. 109, 2616-2624 (2001)] that a small spherical scatterer is in general associated with four eigenvalues and eigenvectors of the time-reversal operator. In this paper, the 2D problem of scattering by an elastic cylinder, imbedded in water, measured by a linear array of transducers is considered. In this case, the array response matrix has three nonzero singular values. Experimental results are obtained with linear arrays of transducers and for wires of different diameters smaller that the wavelength. It is shown how the singular value distribution and the singular vectors depend on the elastic velocities cL, cT, the density rho of each wire, and on the density rho0 and velocity c0 of the surrounding fluid. These results offer a new perspective towards solution of the inverse problem by determining more than scattering contrast using conventional array processing like that used in medical ultrasonic imaging.

Journal Article↗

PubMed2003

Is laparoscopic radical prostatectomy better than traditional retropubic radical prostatectomy? An analysis of peri-operative morbidity in two contemporary series in Italy.

OBJECTIVE: To compare morbidity in two groups of patients who underwent retropubic or laparoscopic radical prostatectomy in the same period. PATIENTS AND METHODS: The clinical and pathological data obtained in 50 consecutive patients who underwent retropubic radical prostatectomy (RRP) from January 2001 to December 2001 were compared to those obtained in 71 consecutive patients who were treated in the same year by extraperitoneal laparoscopic radical prostatectomy (LRP). The two groups were comparable in terms of mean pre-operative PSA and biopsy Gleason score. The peri-operative data included operative time, intra-operative and post-operative transfusion rates, complication rates, hospitalization length, and duration of catheterization. The following pathological parameters were considered: Gleason score, pathological stage, and positive surgical margin rate. A comparative evaluation of continence recovery (no pads and any leakage) was made only in patients with follow-up longer than 12 months. RESULTS: The two groups were comparable in terms of pathological stage and definitive Gleason score. Operating times were significantly shorter in RRP (p<0.0001). LRP patients showed higher autologous (p<0.001) and eterologous transfusion (p=0.03). No significant difference was observed in terms of complication rates (p=0.07). The rectal injury rate was 2.8% in the laparoscopic group. The mean post-operative hospital stay was 10.2+/-2 days in the surgery group and 7.2+/-3.4 days in the laparoscopy group (p<0.001). Catheterization time was 8.4+/-0.9 days in the surgery group and 8+/-2.8 days in the laparoscopy group (p=0.27). After 12 months, complete continence was achieved in 64% of RRP and 40% of LRP patients, respectively (p=0.29). CONCLUSION: The results of our non-randomized study show that up to now laparoscopic radical prostatectomy does not provide significant advantages in terms of peri-operative morbidity compared with the traditional retropubic approach.

Aged↗

PubMed1998

Ultrasonically activated shears in thyroid surgery.

BACKGROUND: Ultrasonically activated shears (UAS) have been documented to be both safe and fast devices in laparoscopic surgery. We studied whether the use of UAS would have some advantage in thyroid surgery. METHODS: Thyroidectomies, performed by one senior endocrine surgeon between December 1996 and February 1997, were retrospectively matched, with patients operated on by the same surgeon using the conventional method. RESULTS: Six pairs of total thyroidectomies and one pair of lobectomies could be matched. Mean operating time was 100 minutes for the patients operated on with the UAS and 154 minutes for the patients operated on with the conventional method. The mean operating time with the UAS was thus on average 64.6% of the operation time with the conventional method, with a 95% confidence interval from 50.1% to 83.5% (t = 4.00, 6 df, P = 0.007). CONCLUSIONS: In this material the use of UAS reduced significantly operating time in thyroidectomies.

Blood Loss, Surgical↗

PubMed2002

Tension-free vaginal tape procedure for the treatment of stress urinary incontinence: the first experience in Thailand.

OBJECTIVE: Tension-free vaginal tape (TVT) is gaining popularity as an effective treatment for genuine stress urinary incontinence. To better understand this procedure including its results, a retrospective study was carried out to determine surgical technique, effectiveness, safety and early results of this new continence procedure. MATERIAL AND METHOD: From January 1999 to July 2000, twenty female patients with the mean age of 52 years old underwent the TVT procedure. All of them were done by a small incision at mid urethra and a special instrument was used to apply a polypropylene mesh supporting the urethra. Urethral catheter was used as urinary drainage which was removed the next day. Operative time, post-operative course, voiding patterns and residual urine were recorded. RESULTS: Mean operative time was 32 minutes (range 15-45 minutes). Up to 10 months, all of the patients were subjectively cured. There was no significant per- and post-operative complication including blood loss, wound infection and severe pain. Four patients (20%) had marked residual urine (>100 ml) and needed clean intermittent catheterization for the mean of 0.7 week. CONCLUSION: Although the follow-up period was short, the TVT procedure seems to be a safe and effective method for the treatment of stress urinary incontinence.

Aged↗

PubMed2003

Simultaneous abdominal aortic aneurysm repair during the on-pump coronary artery bypass grafting.

A case of simultaneous coronary artery bypass grafting (CABG) and abdominal aortic aneurysm (AAA) repair on cardiopulmonary bypass (CPB) is reported. A 74-year-old man was diagnosed with left main coronary disease and infrarenal AAA. Triple CABG and infrarenal AAA repair were performed simultaneously, by different surgeons, on CPB. The duration of CPB, aortic clamp time, and total operation time was 81 min, 33 min, and 245 min, respectively. The patient was extubated three hours after ICU admission and the postoperative course was uneventful. This method is useful for reduction of operation time, for blood salvage, and for adjustment of preload and afterload of the vulnerable heart during AAA repair.

Aged↗

PubMed2003

[The learning curve in the context of the cesarean section].

BACKGROUND: We created learning curves to define an objective figure according to which residents are capable of performing a cesarean section responsibly without supervision. METHODS: We established learning curves of 9 different outcome variables related to cesarean section for all trainees of obstetrics-gynecology in the years 1995-1999 (blood loss, length of stay, Apgar score, umbilical cord pH value, induction-delivery time, uterotomy-delivery time and total operation time). The change from the steep to the flat part of the curve was determined visually and defined as the end of the initial learning phase. RESULTS: 15 residents performed a total of 371 sections. Concerning the operation time and the induction-delivery time, the steep part of the curve was exceeded after 20 sections. For the 1-min Apgar score and the length of stay, only a slight change in the curve was present; for the remaining parameters, no learning process could be demonstrated. CONCLUSION: For cesarean sections of average risk, 20 procedures are adequate to provide sufficient safety for the patient.

Apgar Score↗

PubMed2000

Piggyback technique and selective use of veno-venous bypass in adult orthotopic liver transplantation.

BACKGROUND: The piggyback technique (PT), with preservation of the cava, is being used more frequently in adult orthotopic liver transplantation (OLT). The advantages of PT include hemodynamic stability during the anhepatic phase without a large-volume fluid infusion and obviating the need for veno-venous bypass (VVB). At our center, we changed our practice in July 1997 from the standard technique (ST) of OLT with routine use of VVB to PT and selective use of VVB. The purpose of the present study was to analyze the results with the two different practices, ST-routine VVB versus PT-selective VVB. METHODS: Forty OLTs were performed during the period July 1995 July 1997 using ST-routine VVB (group I) and 36 during August 1997-December 1998 using PT-selective VVB (group II). The etiology of liver disease was similar in the two groups, with hepatitis C and alcoholic liver disease accounting for half of the patients in each group. The UNOS status, age, sex, and percentage of patients with previous upper abdominal surgery were also similar between the two groups. RESULTS: In the PT-selective VVB era (group II), 34/36 patients (94%) underwent OLT with PT and VVB was used for 8 (22%) patients. The decision to use VVB was elective for 3 patients (fulminant hepatic failure, 2; severe portal hypertension, 1) and urgent for 5 patients (hemodynamic instability during hepatectomy). The intraoperative use of packed red blood cells (PRBC) (mean +/- SD) was 15+/-12 units for group I and 9+/-8 units for group II (p = 0.023). Anastomosis time and total operating time (mean +/- SD) were 91 + 30 min and 9.5+/-3.2 h, respectively, for group I patients compared with 52+/-28 min and 7.6+/-1.6 h, respectively, for group II patients (p<0.0001 and 0.002, respectively). Median post-operative stays in the intensive care unit (ICU) and in the hospital were 5 and 17 d, respectively, for group I and 4 and 11 d, respectively, for group II (p = NS). Mean serum creatinine on day 3 was similar in the two groups. Median hospital charges for group I patients were $105439 compared with $91779 for group II patients (p = NS). The 1-year actuarial graft and patient survival rates were 78% and 82%, respectively, for group I, and 92% and 95%, respectively, for group II. CONCLUSIONS: PT is safe and can be performed in the majority of adult patients (>90%) undergoing OLT. With the routine application of the piggyback procedure, the use of VVB has been reduced to 20% of OLTs at our center. The practice of piggyback technique with the selective use of VVB is associated with shorter anhepatic phase and total operating time, lower blood product use, a trend towards shorter hospital length of stay, and reduced hospital charges compared with standard technique of OLT with routine use of VVB.

Female↗

PubMed2002

[Radical surgery in tumors of the thoraco-lumbar spine].

PURPOSE OF THE STUDY: In this retrospective study, the outcomes of anterior and posterior approaches, performed either simultaneously or consecutively, in the radical surgical treatment of tumors of the thoracolumbar spine were compared in terms of surgery duration, intra-operative blood loss, neurological findings and complications. MATERIAL: A total of 547 patients with malignant tumors of the spine were treated between 1981 and 2001. Of these, the thoracolumbar spine was affected in 422 cases. Spondylectomy from the combined anterior and posterior approach with decompression, vertebral body replacement and stabilization was indicated in 117 patients, 69 men and 48 women (59% and 41%, respectively). Etiology included metastases in 63 subjects (54%), primary malignant tumor in 37 (32%), benign tumors in 11 (9%) and tumor-like lesions in six patients (5%). Surgery involving two procedures carried out simultaneously by two teams of surgeons was used in 45 cases (38%) and approaches performed consecutively (in either the anteroposterior or the posteroanterior order) were applied in 72 cases (62%). Both groups were nearly identical in relation to the patients' average age and disease etiology. METHODS: In young patients with a solitary tumor of the thoracolumbar spine whose disease had a good prognosis, radical surgery including complete removal of the vertebra affected, decompression of nervous structures, vertebral body replacement and stabilization with 360 degrees fusion was carried out. The simultaneous and consecutive procedures were compared in terms of operative time, intra-operative blood loss, neurological findings and complications. RESULTS: The approaches carried out simultaneously by two teams reduced the total time of surgery and permitted a better correction of the spine affected. This surgical procedure, however, was more demanding in terms of operative skills and involved increased intraoperative blood losses. In 45 patients treated by this procedure, the average operative time was 244 min and intra-operative blood loss was 3313 ml. In 72 patients undergoing consecutive surgery, the average operative time was 345 min and blood loss was 2500 ml. The neurological finding was generally better or unchanged. Of the patients treated consecutively, four (5.5%) experienced deterioration; of those operated on simultaneously, only one patient (2.2%) got worse. Two patients died in each group (2.8% and 4.4%, respectively). DISCUSSION: In order to provide the optimal therapy, each cancer patient should be considered individually with respect to all basic rules of cancer treatment. In this, the radical approach is nowadays preferred. Some authors, however, use only the posterior approach. At our department, the combined anteroposterior approach under one anesthesia is our method of choice with the exception of a serious intra-operative complication such as large blood loss. In this case, the treatment is completed at a subsequent operation one week later. CONCLUSIONS: We prefer an active and radical approach to the therapy of spinal tumors. The simultaneous surgery resulted in an operative time reduced by about 100 min (29%). The consecutive treatment, on the other hand, produced lower blood losses by 813 ml (24%). Complete surgery under one anesthesia was preferred.

Adolescent↗