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PubMed1995

[Increased intraocular pressure after cataract extraction--effect of surgical technique, surgical procedure and preventive drug administration. A prospective, randomized double-blind study].

BACKGROUND: We performed a double-masked, randomized and prospective study to compare the effect of surgical technique, surgeon's experience, and prophylactic medication on the intraocular pressure rise after cataract extraction. PATIENTS AND METHODS: Intraocular pressure of 120 patients was measured the day before, as well as two to four, five to seven and 22 to 24 hours after uncomplicated cataract extraction. 47 patients were operated with phacoemulsification and sclerocorneal sutureless tunnel (phaco/tunnel). 61 patients with phacoemulsification and corneoscleral incision and suture (phaco/suture), and 12 patients with extracapsular technique (ECCE). 48 operations were done by inexperienced surgeons (less than 200 intraocular operations), 72 by experienced surgeons (300-2000 intraocular operations). Patients were treated with either levobunolol, acetazolamide, apraclonidine, or placebo. Each treatment group contained 30 patients. RESULTS: In all groups, the mean intraocular pressure increased to a maximum at five to seven hours after surgery. The pressure rise was significantly higher in the ECCE group (20.6 mm Hg) than in the phaco/suture group (10.5 mm Hg) and in the phaco/tunnel group (5.4 mm Hg, p always < 0.05). Eyes operated by inexperienced surgeons had a significantly (p < 0.005) greater pressure rise (12.9 mm Hg) than eyes operated by experienced surgeons (7.1 mm Hg). Treatment had no significant (p = 0.41) effect on the intraocular pressure rise. CONCLUSION: The intraocular pressure rise after cataract extraction strongly depends on the surgical technique and to a lesser extent, on the surgeon's experience. At least for phacoemulsification, the effect of the prophylactic medication used in this study is small and appears to be clinically irrelevant.

Acetazolamide↗

PubMed1994

[Astigmatism against the rule after small incision cataract surgery. A multifactorial, multivariate study].

BACKGROUND: Small-incision cataract surgery has been further developed by the introduction of the sutureless technique. This procedure has reduced operation time and the surgically induced astigmatism compared to closure technique. PATIENTS AND METHODS: We evaluated 426 patients operated by the same surgeon using the same intraoperative approach. Patients were monitored for postoperative induced astigmatism and postoperative complications. RESULTS: Our results demonstrated small induced astigmatism after one week and one month. The no-stitch technique showed the smallest postoperative astigmatism with the least variation. With multivariate methods we also analysed several factors influencing the axis of the induced astigmatism. CONCLUSION: The most important factor for a postoperative astigmatism against the rule is using the no-stitch-technique and the existence of a preoperative astigmatism against the rule.

Astigmatism↗

PubMed2004

Corneal reconstruction with tissue-engineered cell sheets composed of autologous oral mucosal epithelium.

BACKGROUND: Ocular trauma or disease may lead to severe corneal opacification and, consequently, severe loss of vision as a result of complete loss of corneal epithelial stem cells. Transplantation of autologous corneal stem-cell sources is an alternative to allograft transplantation and does not require immunosuppression, but it is not possible in many cases in which bilateral disease produces total corneal stem-cell deficiency in both eyes. We studied the use of autologous oral mucosal epithelial cells as a source of cells for the reconstruction of the corneal surface. METHODS: We harvested 3-by-3-mm specimens of oral mucosal tissue from four patients with bilateral total corneal stem-cell deficiencies. Tissue-engineered epithelial-cell sheets were fabricated ex vivo by culturing harvested cells for two weeks on temperature-responsive cell-culture surfaces with 3T3 feeder cells that had been treated with mitomycin C. After conjunctival fibrovascular tissue had been surgically removed from the ocular surface, sheets of cultured autologous cells that had been harvested with a simple reduced-temperature treatment were transplanted directly to the denuded corneal surfaces (one eye of each patient) without sutures. RESULTS: Complete reepithelialization of the corneal surfaces occurred within one week in all four treated eyes. Corneal transparency was restored and postoperative visual acuity improved remarkably in all four eyes. During a mean follow-up period of 14 months, all corneal surfaces remained transparent. There were no complications. CONCLUSIONS: Sutureless transplantation of carrier-free cell sheets composed of autologous oral mucosal epithelial cells may be used to reconstruct corneal surfaces and can restore vision in patients with bilateral severe disorders of the ocular surface.

Aged↗

PubMed2003

Briefly occlusive coronary anastomosis with tissue adhesive.

OBJECTIVE: We assessed the feasibility of a facilitated, briefly occlusive, sutureless coronary anastomosis technique in which side-to-side preglued (octylcyanoacrylate adhesive) bounded walls were opened by a conventional arteriotomy. METHODS: In low-flow (prothrombotic milieu, <or=15 mL/min, n = 8) and high-flow (approximately 50 mL/min, n = 8) porcine model of off-pump internal thoracic artery-left anterior descending coronary artery bypass, the anastomoses were evaluated intraoperatively (n = 16) and at 5 weeks (n = 14, with 2 evaluated at 2.5 weeks). The anastomoses were examined by flow measurement, angiography, and histologic studies. RESULTS: Coronary occlusion lasted a median of 1.6 minutes (15th-85th percentile 1.4-1.8 minutes), and anastomosis construction required a median of 5.5 minutes (15th-85th percentile 4.2-6.5 minutes). At 5 weeks all anastomoses were fully patent (FitzGibbon grade A), with an angiographic appearance similar to an end-to-side anastomotic configuration. CONCLUSIONS: The briefly occlusive adhesive anastomosis technique proved to be feasible in off-pump bypass surgery in the pig even under prothrombotic low bypass graft flow conditions (<or=15 mL/min). Further studies are warranted to investigate the applicability of this technique to endoscopic bypass surgery on the beating heart.

Anastomosis, Surgical↗

PubMed2002

Multicenter trial of the PowerLink bifurcated system for endovascular aortic aneurysm repair.

PURPOSE: The purpose of this study was to assess the results of abdominal aortic aneurysm repair with the PowerLink bifurcated endovascular graft (Endologix, Inc, Irvine, Calif). METHOD: Twelve centers used the PowerLink bifurcated system for elective endovascular aneurysm repair in 118 patients recruited during a 16-month interval and followed for a 25-month interval (mean follow-up, 16 months) as part of a pivotal US Food and Drug Administration trial. Stent grafts were oversized by 10% to 20% relative to computed tomographic scan-based diameter measurements. All repairs were performed in the operating room through one surgically exposed femoral artery and a contralateral 9F sheath percutaneously placed. Results were assessed with contrast-enhanced computed tomography and plain abdominal radiography at 1, 6, and 12 months after surgery. RESULTS: Three failed insertions and one late conversion for endoleak remediation occurred, resulting in four conversions (3.3%) to open surgery. Of the failed insertions, two were from a faulty delivery system design, which was corrected. No failures occurred after the modification. One perioperative death (0.8%) occurred that was not device related. Eight late deaths were from unrelated causes, and one was from complications after reoperation for treatment of an endoleak. Endoleaks were noted in 19 patients (16%) at the time of the endograft procedure: 12 resolved spontaneously, four resolved with secondary interventions (three type I, one type II), and three underwent observation, yielding a 30-day endoleak rate of 5.9%. Two graft limb thromboses (0.8%) were seen. One graft migration (0.8%) was of no clinical significance. No ruptures or wire fractures were found. The mean aneurysm diameter was reduced from 51 mm (preoperative) to 45 mm (12 months; P <.0001). CONCLUSION: The PowerLink system appears to be safe and effectively protects patients from abdominal aortic aneurysm rupture over the short to medium term. The low endoleak rate is superior to that reported for other devices. The graft and stent materials have thus far been free from failure and fatigue. The sutureless stent and endoskeleton design confer a number of unique advantages and challenges. Careful follow-up over the longer term is necessary to assure the durability of these results.

Aged↗

PubMed2002

Repair of facial nerve with alginate sponge without suturing: an experimental study in cats.

A bioabsorbable material, alginate, was used to repair a defect in the facial nerve. In five cats a 5-mm gap was created in the dorsal ramus of the facial nerve on one side selected at random, which was repaired by implantation of alginate sponge without suturing. In the control group, two cats had a similar nerve injury but without implantation of alginate. Behavioural, electrophysiological, and histological examinations were made over a period of 16 weeks postoperatively. Movement of the upper eyelids and electrophysiological function were restored 12 weeks postoperatively, and many myelinated axons were observed both in the gap of facial nerve and its branches 16 weeks after operation, whereas no alginate residue was detected remaining within gap. In the control group, no movement or electrophysiological restoration was recorded, and there were few regenerated axons accompanied by a large amount of scar tissue. The nerve repaired with alginate showed remarkable regeneration. These results suggest that alginate is a promising material for facial nerve repair, and sutureless repair with alginate is a possible option for treating defects in the facial nerve.

Alginates↗

PubMed1990

Laser vascular tissue fusion: development, current status, and future perspectives.

Tissue fusion has a number of vascular applications such as making sutureless blood vessel anastomoses and for securing the end points of endarterectomies and dissection planes. Precision of tissue apposition at the time of fusion has been found to be a critical parameter, affecting the rate of healing and tensile strength of tissue welds. Several laser wavelengths can be used to accomplish vascular and other soft tissue fusions. Potential advantages of laser fusion over suture techniques may include healing without foreign body reaction related to sutures and preserved mechanical properties at anastomoses. While preliminary experimental and clinical data are very promising, additional work is needed. This would include determining the mechanism and optimal laser parameters and wavelengths required for vascular tissue fusion. In addition, the characteristics needed to seal uniformly large-diameter arteries and to fashion welds that withstand systemic arterial pressures must be identified. Follow-ups of approximately three years suggest that strong initial primary seals will eliminate significant adverse effects.

Adult↗

PubMed1988

A new mechanical device for circular compression anastomosis. Preliminary results of animal and clinical experimentation.

The authors report the preliminary results obtained in animal and clinical experimentation of a new mechanical device for circular anastomosis which they have developed. It is a gun that places an apparatus consisting of three polypropylene rings that, through the compression among them of the severed edges of the bowel, realize a sutureless anastomosis and are spontaneously evacuated. Fifty-eight colonic anastomoses were performed in dogs with this device; 23 stapled colonic anastomoses were also executed concurrently. Forty-four animals underwent a relaparotomy to remove the colonic specimen containing the anastomoses. Bursting pressure and the histologic features of the anastomoses were evaluated at different time intervals after operation. A good healing of all compression anastomoses was observed, thereby allowing them to initiate the experience in humans. Thirteen anastomoses (6 colorectal extraperitoneal, 1 colorectal intraperitoneal, 5 colocolonic, 1 ileorectal) were performed at the 1st Surgical Department, Milan University. One subclinical leakage (7.7%) spontaneously healed in a few days. No stenoses were observed.

Adult↗

PubMed2001

Minimally invasive CABG.

For more than three decades, conventional coronary artery bypass grafting (full sternotomy, cardiopulmonary bypass, and cardioplegic arrest) has been the treatment of choice for patients with multi-vessel coronary artery disease. However, neurologic injury secondary to ascending aortic manipulation and systemic inflammatory reaction related to cardiopulmonary bypass are major causes of morbidity. During the past decade research efforts have been focused on the development of innovative revascularization techniques to minimize these deleterious effects. Minimally invasive direct coronary artery bypass surgery was developed to reduce chest trauma and to accelerate patient recovery. The relatively recent introduction of mechanical stabilizers and positioning devices has allowed for the safe performance of off-pump coronary artery bypass for patients with multi-vessel disease. Robotic technology has offered the possibility of myocardial revascularization through limited access using endoscopic principles. Recently, emphasis has been placed on the development of new sutureless anastomotic devices that may revolutionize the field of myocardial revascularization and allow a broader acceptance of minimally invasive CABG. Despite the increasing availability of new technologies, the validity of these procedures must be evaluated carefully. Prospective randomized studies and longitudinal follow-up will be required.

Coronary Artery Bypass↗

PubMed2002

A photopolymerized sealant for corneal lacerations.

PURPOSE: To determine whether a novel photocrosslinkable polymer synthesized from hyaluronic acid would seal experimental full-thickness corneal lacerations in a rabbit model. METHODS: A solution of hyaluronic acid was modified with methacrylate groups (HA-MA), precipitated, dried, reconstituted in an aqueous solution, and sterilized before use. The viscous polymer solution was applied to 38 of 43 experimental corneal lacerations in rabbits and subsequently irradiated with a low-intensity argon laser beam to produce a clear flexible polysaccharide hydrogel patch. The ability of this sealant to repair corneal lacerations was evaluated in four types of full-thickness, 3-mm corneal wounds (linear, linear + epithelium removed, stellate, and stellate + epithelium removed). Slit-lamp examinations, measurements of intraocular pressure, Seidel tests, and histologic studies were performed at selected intervals to evaluate the wound and determine the rate of healing. RESULTS: Corneal perforations were completely sealed and the anterior chambers had reformed by 6 hours in HA-MA-treated eyes. There was no evidence of leakage at this or later times in 37 of the 38 eyes. Intraocular pressure had risen to near-normal levels by day 7 in all four groups, and the sealant was still present in most eyes at day 7. In contrast, the anterior chambers did not re-form in control eyes (five) with untreated perforations because of aqueous leakage through the wounds. Minimal inflammation was observed clinically or in histologic sections of treated corneas. There was extensive proliferation of stromal cells and formation of new extracellular matrix at the wound edges, which became tightly adherent between days 4 and 7. CONCLUSION: Our novel photocrosslinkable methacrylated hyaluronan polymer sealed 97% (37/38) of the experimental corneal lacerations. HA-MA may prove useful for sealing corneal lacerations in patients and for other sutureless ophthalmic surgical procedures.

Animals↗

PubMed1998

Technique and outcome of combined phacoemulsification and trabeculectomy.

The efficacy of combined surgery for the treatment of concurrent glaucoma and cataract has long been under scrutiny. Comparisons between sequential surgery and combined procedures have shown mixed results, and current guidelines have been drawn for the indication of combined surgery. The evolution of combined triple surgery--cataract extraction, intraocular lens implantation, and filtering procedure--has evolved from planned extracapsular cataract extraction to small-incision phacoemulsification. The improvements of phacoemulsification over extracapsular surgery have naturally given rise to improvements in the results of combined procedures; good outcomes in both intraocular pressure control and visual acuity have been reported along with low complication rates. The techniques of combined phacoemulsification-trabeculectomy are under continual development as new sutureless incisions, filtration procedures, and antimetabolite use are studied. The results of numerous studies show that the combined procedure is an effective method of treatment of glaucoma and cataract. This review examines various recent aspects of the combined procedure, phacoemulsification-trabeculectomy, antimetabolites, results and complications, as well as current developments of new techniques. In addition, we review studies on combined cataract extraction and trabeculectomy, including older literature on planned extracapsular extraction plus trabeculectomy as well as newer studies on phacoemulsification-trabeculectomy.

Antimetabolites↗

PubMed2002

New techniques in lamellar keratoplasty.

In the past years, several lamellar keratoplasty surgical techniques have been developed, modified or improved in the past years, including microkeratome assisted anterior and posterior lamellar keratoplasty, anterior lamellar keratoplasty using air-dissection or visco-dissection, sutureless posterior lamellar keratoplasty, LASIK for postkeratoplasty astigmatism, and excimer laser assisted keratophakia for keratoconus or to manage complications after LASIK. These procedures may continue to gain interest as alternative procedures for a penetrating keratoplasty in the treatment of various corneal disorders.

Corneal Transplantation↗

PubMed2004

Central renal stab wounds: treatment with augmented fibrin sealant in a porcine model.

PURPOSE: We determined whether fibrin sealant augmented by an absorbable bolster could salvage kidneys with major, centrally located stab wounds. MATERIALS AND METHODS: A grade 4 renal injury was created in 16 commercial swine via a 1.5 cm sagittal, centrally located, through-and-through right renal laceration. Animals were randomized to 1 of 4 treatment arms, including control groups that received conventional renal capsule suture repair with an absorbable gelatin sponge bolster (3 in group 1) or a microfibrillar collagen sheet (3 in group 2) and experimental groups that received sutureless treatment entailing fibrin sealant instillation into the knife tract augmented by an external gelatin sponge (5 in group 3) or an external microfibrillar collagen sheet (5 in group 4). Arterial occlusion was not performed. Blood loss and time to hemostasis were recorded. Abdominal computerized tomography was performed at 1 week and necropsy was done at 6 weeks. RESULTS: Renal reconstruction with fibrin sealant resulted in significantly lower blood loss (62 vs 155 ml, p <0.05) and time to hemostasis (3.5 vs 6.5 minutes, p <0.05) than in the conventional suture groups. There was no radiographic or gross evidence of significant postoperative bleeding, urinoma formation or abnormal tissue healing in the recovery period. Gelatin sponge and collagen sheet demonstrated similar hemostatic efficacy. CONCLUSIONS: In this porcine renal trauma model fibrin sealant augmented by absorbable gelatin sponge or a microfibrillar collagen sheet effectively promoted hemostasis and renal salvage. Because of its safety, ease of use and efficiency, fibrin sealant appears to be an appropriate adjunct for managing challenging renal injuries.

Animals↗

PubMed2005

Gelatin matrix treatment of complex renal injuries in a porcine model.

PURPOSE: We developed a complex porcine renal laceration model at our laboratory to test the efficacy of an abbreviated, sutureless treatment regimen using FloSeal gelatin matrix hemostatic sealant (Baxter Healthcare Corp., Fremont, California). We evaluated the influence of preliminary renal arterial occlusion on hemostatic efficacy and assessed the risk of delayed hematoma or urinoma formation after treatment. MATERIALS AND METHODS: A total of 21 commercial swine underwent celiotomy with creation of a complex upper pole renal injury using a 4 x 4 cm cruciate press instrument. The injury was uniformly produced at the caudal extent of the upper third portion of the left kidney. Subjects were prospectively randomized into 3 treatment groups. Experimental animals were treated with the application of gelatin matrix with (7 in group 1) or without (7 in group 2) preliminary renal arterial occlusion. Control subjects (7 in group 3) were treated with conventional horizontal mattress sutured gelatin sponge bolsters over the capsular injury. Operative blood loss, time to hemostasis and volume of gelatin matrix required for hemostasis were compared among the groups. Abdominal computerized tomography with intravenous contrast medium was performed in each animal 7 days postoperatively. RESULTS: Gelatin matrix use resulted in significantly less mean blood loss (80.7 and 99.0 ml in groups 1 and 2, respectively) vs conventional suture treatment (191.8 ml in group 3, p = 0.036). Time to hemostasis was similarly decreased (1.1, 2 to 2.5 and 5.8 minutes in groups 1 to 3, respectively, p = 0.009). Followup abdominal computerized tomography with contrast medium revealed no clinically significant perinephric fluid collections (greater than 2 cm). CONCLUSIONS: FloSeal gelatin matrix hemostatic sealant provided effective hemostasis after complex renal injury with and without preliminary vascular control. No delayed bleeding or clinically significant urinoma formation was noted. These findings suggest a possible increased role for FloSeal gelatin matrix in renal salvage surgery.

Animals↗

PubMed2005

Fibrin glue v sutured bolster: lessons learned during 100 laparoscopic partial nephrectomies.

PURPOSE: Laparoscopic partial nephrectomy (LPN) is performed with marked technical variations. We defined the limits of sutureless LPN and determined which closure technique is best in a particular situation. MATERIALS AND METHODS: During 100 consecutive LPNs fibrin glue products were used for closure in the first 75 (group 1) and sutured bolsters were applied when the collecting system (CS) or renal sinus was entered in the final 25 (group 2). RESULTS: In groups 1 and 2 hand assisted laparoscopy was used in 72% vs 40% of cases and hilar clamping was used in 27% vs 92%, respectively. Mean tumor size was 25 vs 26 mm, tumor depth was 11 vs 13 mm, distance to the renal sinus was 9 vs 5 mm, operating room time was 185 vs 210 minutes, estimated blood loss was 398 vs 247 cc and hospital stay was 2.9 vs 2.6 days in groups 1 and 2, respectively. Overall postoperative hemorrhage and urine leakage occurred in 9% and 2% of patients, respectively. Tumors associated with postoperative hemorrhage/leakage tended to be larger (35 vs 24 mm, p = 0.007) and closer to the renal sinus (0.5 vs 8.2 mm, p = 0.02). Postoperative hemorrhage or urine leakage occurred in 41% of the 17 patients in group 1 with CS or renal sinus entry but in only 2 of the 58 (3.4%) without entry (p <0.0001). In group 2 hemorrhage/leakage occurred in 11% of the 18 patients with CS or renal sinus entry (vs same subset in group 1, p = 0.04). CONCLUSIONS: LPN with closure using fibrin glue products provides adequate hemostasis when the CS or renal sinus is not entered. When the CS or renal sinus is entered, a sutured bolster is recommended.

Decision Trees↗

PubMed1983

Extraction of chronically infected transvenous pacemaker leads: report of an unusual problem.

This is a report of a patient with an impacted, chronically infected transvenous pacemaker lead whose management was complicated by the presence of a functioning contralateral transvenous pacemaker. Treatment included sustained traction on the infected lead, a left subcostal thoracotomy for placement of new sutureless epicardial leads, and retrograde right iliac vein cannulation for final snare removal of the mobilized lead. The patient is currently free of infection, and has normal pacemaker function.

Aged↗

PubMed1984

One turn more: threshold superiority of 3-turn versus 2-turn screw-in myocardial electrodes.

Epicardial electrodes are an alternative for patients in whom the transvenous approach presents technical difficulties. We have had clinical experience with two types of myocardial sutureless electrodes inserted in the anterior left ventricular wall: the 3-turn screw-in electrode (Medtronic 6917) was used in 209 patients from 1974 to 1977 and the 2-turn screw-in lead (Medtronic 6917 A) was used in 61 patients from 1978 to 1981. The initial threshold was equal and acceptable with both types of electrodes. During a follow-up period (up to 48 months), critical elevation of the pacing threshold resulting in exit block was found in 12% (25) of the patients with the 3-turn screw-in electrode and in 20% (12) of the patients with the 2-turn electrode (p less than 0.05). Elevation of the pacing threshold developed fairly early, usually within 6 months, with the 2-turn screw-in electrode, but much later, within 2-4 years, with the 3-turn electrode. During a longer follow-up time of up to 96 months the frequency of exit block increased up to 16% with the 3-turn electrode. Our results indicate that late critical elevation of the pacing threshold is surprisingly frequent with screw-in electrodes inserted into the left ventricular myocardium, and it is especially common with the 2-turn screw-in electrode.

Adolescent↗

PubMed1988

Comparison of two myoepicardial pacemaker leads: follow-up in 80 children, adolescents, and young adults.

Although several types of commercially available epicardial leads exist, few postimplantation data have been reported. To compare "screw-in" (6917-35) leads with "stab-on" leads (4951-35) from the same manufacturer, we reviewed the records of 80 young patients (age 8 days to 29 years) who underwent ventricular epicardial pacemaker implantation from 1973 to 1986. Follow-up for the 57 patients with the 6917-35 model ranged from 3 months to 17 years (median 6.5 years) and for the 23 patients with the 4951-35 model 9 days to 4.25 years (median 2.0 years). Actuarial life table analysis revealed significantly (P less than 0.001) fewer 4951-35 leads were functioning at each of 1-5 years after implant, compared to the 6917-35 leads. Analysis of available threshold pulse width data revealed no difference (P = 0.08) acutely (6 weeks after implant), but a significantly (P = 0.05) higher mean threshold for the 4951-35 leads was found chronically. No significant correlation was found for lead failure with age, underlying heart disease, lead site (i.e., left or right ventricle), or surgical approach. Using the sutureless, stab-on technique, the 4951-35 lead is associated with higher thresholds and lower survival rate when compared to the 6917-35 lead.

Actuarial Analysis↗