PURPOSE: Many patients who have advanced cancer of the neck will have involvement of the internal carotid artery. The management of this condition remains controversial, and a wide range of therapeutic options have been suggested including ligation, "shaving" the tumor off the carotid, or en bloc resection and replacement of the internal carotid artery by polytetrafluoroethylene, vein, or superficial femoral artery. We reviewed our experience with en bloc resections of the internal carotid artery in a consecutive series of patients who had malignancies involving the internal carotid artery at a single institution from 1989 to 1995. METHODS: We used a retrospective chart review based on a list of 20 patients generated by the Hospital Cancer Registry and our Vascular Surgery clinical database. RESULTS: All patients had their internal carotid artery removed and replaced with a greater saphenous vein while they were under general anesthesia. A resection of their cervical malignancy was also performed. Concomitant myocutaneous flaps were rotated over the carotid bypass in six (30%) patients. Eight (40%) of the bypass grafts were nonreversed, and 12(60%) were reversed, with a clear trend towards using nonreversed veins more recently. Shunts were used in 18(90%). Eighteen of the 20 patients had some form of intraoperative contamination including tracheostomies, pharyngostomies, or fistulas. Half of the patients had intraoperative radiation therapy, and 16(80%) patients underwent operation for recurrent cancer. During the follow-up period two (10%) patients had strokes (one minor and one major), and one patient had a graft blowout, which was treated by ligation without stroke. One patient had an asymptomatic occlusion of his graft. CONCLUSIONS: From these results we conclude that the use of the greater saphenous vein to replace the internal carotid artery after en bloc resection is not attended by a high rate of infectious complications or graft blowout even in the presence of intraoperative tracheopharyngeal contamination and that the greater saphenous vein is the conduit of choice for replacing an internal carotid artery after cancer resections.

Carcinoma, Squamous Cell↗

PubMed1996

A randomized prospective clinical trial of the Taylor patch.

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Anastomosis, Surgical↗

PubMed1996

The minimal important difference: who's to say what is important?

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Differential Threshold↗

PubMed1996

Complete atrioventricular septal defects: the influence of associated cardiac anomalies on surgical management and outcome.

OBJECTIVE: Major associated cardiac anomalies are known to increase the risk of repair of complete atrioventricular septal defects (CAVSDs). The purpose of this study was to examine the effects of such anomalies on the current surgical management of CAVSDs and their influence on outcome following repair. METHODS: We performed a retrospective review of a 100 consecutive non-isomeric patients undergoing repair of CAVSD at our institution, between January 1989 and December 1994; patients with partial or intermediate defects were excluded. Complete atrioventricular septal defect patients with other major cardiac abnormalities (complex) were then compared to those with isolated CAVSDs. RESULTS: There were 15 patients (15%) with associated anomalies; 3 had tetralogy of Fallot, 1 patient had pulmonary atresia, 6 had hypoplastic left or right ventricle, 1 had tetralogy of Fallot and hyperplastic right ventricle, 2 patients had double outlet right ventricle, 1 had hypoplastic aortic arch and 1 patient had aortic coarctation. The median age at operation was similar for both groups (4.2 months), while the median weight was not significantly different for isolated CAVSDs compared to complex (4.2 months vs 3.4 months, P = 0.89), but there was a higher incidence of trisomy 21 (70/85, 82% vs 8/15, 53.3%, P = 0.01). Two of the 85 isolated CAVSD patients (2.3%) had undergone palliative pulmonary artery banding, while 5 of the 15 complex patients (33.3%) had either banding or Blalock-Taussig shunts performed. The technique of CAVSD repair was identical in each group. All complex patients had standard repair of their associated anomalies. Hospital mortality was higher in the complex group (3/15, 20% vs 2/85, 2.3%, P = 0.004); all early deaths in the complex group occurred in patients with a hypoplastic ventricle. Reoperation for left atrioventricular valve regurgitation was required in six isolated CAVSD patients (7.1%) and in one complex (6.6%). CONCLUSIONS: In the absence of significant ventricular hypoplasia, the early results of surgical repair in patients with CAVSDs and associated cardiovascular anomalies are similar to those achieved in patients with isolated CAVSD.

Aorta, Thoracic↗

PubMed1996

Management and outcome of infants and children with right atrial isomerism.

OBJECTIVES: To assess the current results and outcome of surgery in infants and children with right atrial isomerism and complex congenital heart disease. SETTING: Tertiary referral centre. METHODS: 20 consecutive children with right atrial isomerism and complex congenital heart disease underwent surgery over a 6 year period between August 1987 and July 1993. The results and outcome were analysed according to age, presentation, and surgical procedures. RESULTS: Patients were divided into two groups depending on age at presentation and initial surgery: group A comprised 11 patients who required surgical intervention in the first month of life (mean age 5 days); and group B comprised nine patients who required initial surgical intervention after the first month of life (mean age 6.8 months). Seven (64%) of the 11 patients in group A had obstructed pulmonary venous drainage and ten (91%) had pulmonary atresia. There were seven early deaths (64%), including the five patients who required systemic to pulmonary artery shunt and simultaneous repair of obstructed pulmonary veins. The long-term survival rate in this group was 18% (two of 11). Pulmonary venous obstruction was present in two (22%) of the nine patients in group B and four (44%) had pulmonary atresia. There were no early deaths. One patient died after a second palliative procedure. There was one late sudden death. Four patients had a Fontan operation with no deaths. Two of the remaining three patients meet the Fontan criteria. The long-term survival rate in this group was 78% (seven of nine). CONCLUSIONS: Surgical management of patients with right atrial isomerism who have complex congenital heart disease carries a high mortality and remains palliative. The overall survival rate was 45% (nine of 20); 18% in patients requiring surgery in the first month of life (group A) and 78% in patients requiring surgery after the first month of life (group B) (P < 0.001). Of the total of 20 patients, nine were potential candidates for a Fontan operation. Seven of these have undergone a Fontan procedure with five survivors.

Child, Preschool↗

PubMed1996

Acute slipped capital femoral epiphysis. Review of outcomes and rates of avascular necrosis.

One hundred and forty-nine patients (208 hips) were managed for slipped capital femoral epiphysis at the Hospital for Sick Children in Toronto from 1980 through 1990. We retrospectively reviewed the records of twenty-four patients (twenty-six hips) who had an acute slipped capital femoral epiphysis to evaluate the outcome of treatment and possible risk factors for avascular necrosis associated with this condition. The patients were evaluated with the Iowa hip-scoring system, a physical examination, and anteroposterior and lateral radiographs. The severity of degenerative joint disease was assessed on the radiographs with use of the system described by Boyer et al. Eighteen slips were classified as grade 1; seven, as grade 2; and one, as grade 3, according to the system of Southwick. Twenty-three hips were treated with in situ pinning and three, with reduction and pinning. The mean duration of follow-up was 5.9 years (range, 2.1 to 12.8 years). Poor Iowa hip scores and more severe degenerative changes were related to the development of avascular necrosis and to the severity of the slip. Avascular necrosis developed in four hips (15 per cent), two of which had had a reduction. Multiple logistic regression analysis, which included all 150 slips (both acute and chronic) for which there was adequate follow-up, showed that the rate of avascular necrosis was related to both the severity and the acute nature of the slip.

Acute Disease↗

PubMed1996

The Ilizarov method for correction of complex deformities. Psychological and functional outcomes.

We reviewed the psychological profile and functional ability of forty-five children (fifty-two extremities) who had had correction of deformities of the lower extremities with the Ilizarov method. Psychological changes were evaluated with the Post-Hospitalization Behavior Questionnaire and the Children's Depression Inventory, and the functional status was measured with the Children Health Information Service Rand Scale. The over-all satisfaction of the patient with regard to the outcome of the operation was assessed as well. The operations were performed between 1988 and 1992. The average age at the time of the operation was twelve years (range, three to eighteen years), and the average duration of follow-up was thirty-six months (range, twenty-four to seventy-two months). The lengthening index, duration of lengthening, and average number of complications were similar to those reported in other studies. All of the children had a normal psychological score, forty-two had no limitations in daily activities, and thirty-seven were satisfied with the over-all result.

Activities of Daily Living↗

PubMed1996

Function of dislocated hips in children with lower level spina bifida.

We reviewed 52 children, born between 1974 and 1985 with spina bifida affecting L3 and L4, who had dislocated hips. Their motor function was stable and they were able to walk at the time of dislocation. They were interviewed and examined physically and radiologically. Physical function was measured by the Rand Health Insurance Study questionnaire (HIS), the Childhood Health Assessment questionnaire (CHAQ), and by determining the functional level of ambulation according to Hoffer et al (1973). In a subgroup of 12 patients with L4 level of involvement from both treatment groups we measured the metabolic energy consumption while walking. Thirty patient (49 hips) had been treated by operative relocation and 22 conservatively. Ten of the hips treated by operation subluxated or redislocated. The function in the two groups (conservative nu operated) was similar (HIS score 7.8 v 8.0, p = 0.45; CHAQ 14 v 13, p = 0.2; level of mobility 0.61 v 0.63, p = 0.5). Patients in whom operation had failed had worse function than did those with successful surgery (HIS score 8.8 v 6.1, p = 0.025) and those with successful surgery had better function than patients treated conservatively (HIS score 8.8 v 8.0, p = 0.15). Function in patients with failed operations, however, was worse than in those who did not have surgical treatment (HIS score 6.6 v 7.8, p = 0.07). In the 12 so examined the operated group had a 30% more energy-efficient gait (0.271 v 0.361 ml O2 kg/m, p = 0.05). Patients with failed operations had worse function than those who were not operated on. The benefit of surgical relocation of the dislocated hips was marginal.

Adolescent↗

PubMed1996

Variation in rheumatologists' and family physicians' perceptions of the indications for and outcomes of knee replacement surgery.

OBJECTIVE: To assess agreement among rheumatologists and family physicians (FP) about the indications for knee replacement (KR) referral, use of nonsurgical management options, and perceived outcomes of KR, and to determine the relationship between these opinions and the number of patients seen with severe osteoarthritis (OA) of the knee. METHODS: 98 adult rheumatologists and a random sample of 250 FP in Ontario, Canada were surveyed. Of the practising and traceable rheumatologists and FP, 70.0 and 5.16% responded, respectively. RESULTS: FP disagreed on how 28 of 32 patient factors affected their KR referral decision, while rheumatologists disagreed on 26 of these 32 factors (p = 0.03). Rheumatologists and FP consistently disagreed on the use of 8 of 10 treatments for knee OA (p = 0.37). While rheumatologists and FP reported similar KR outcomes, FP were less in agreement (p = 0.03). Clinical disagreement for the indications for KR (p < 0.0001) and KR outcomes (p < 0.0001) were greater among FP than among orthopedic surgeons who were surveyed in a prior study. Clinical disagreement about the indications for KR was greater among rheumatologists than among surgeons (p = 0.04), but there was no difference in perceived KR incomes (p = 0.18). CONCLUSION: Referring physicians disagreed on the indications for KR referral an on the treatments for knee arthritis, but were in general agreement regarding KR outcomes. Clinical disagreement was greater among FP than among rheumatologists, who in turn reported more disagreement than orthopedic surgeons. Explanations for these difference in perceptions should be the focus of research, but guidelines specifically tailored for each physician specialty may be required to reduce clinical uncertainty.

Adult↗

PubMed1996

Variations in knee replacement utilization rates and the supply of health professionals in Ontario, Canada.

OBJECTIVE: To measure regional variations in knee replacement (KR) utilization rates across the 49 counties of Ontario, Canada, since April 1, 1984, and to evaluate its relationship with the supply of health professionals. METHODS: Utilization data were acquired from the Canadian Institute for Health Information, and physician data were acquired from the Ontario Ministry of Health. There were 18,530 hospitalizations for KR in Ontario between April 1, 1984 and March 31, 1991. Utilization rates were defined as the number of KR procedures for all residents of each county (irrespective of where these procedures were performed) divided by the resident population. Direct methods were used to standardize utilization for age and sex. The extremal quotient, the weighted coefficient of variation, and the systematic coefficient of variation were used as measures of variation. RESULTS: Between fiscal years 1984 and 1990, the extremal quotient fell from 8.1 to 3.4, the weighted coefficient of variation fell from 0.430 to 0.315, and the systematic coefficient of variation fell from 0.215 to 0.142. Utilization was greater in southwestern Ontario (p < 0.001) and lower in Toronto and Durham (p < 0.001) than elsewhere. Utilization in remote areas was not different from that for the province as a whole (p < 0.001). The correlation coefficient between standardized KR utilization and the density of orthopedic surgeons was not significant (p = 0.26) at -0.16, but those for rheumatologists (r = -0.25, p = 0.08) and physical medicine specialists (r = -0.42, p = 0.002) were significant. CONCLUSION: Regional variation in KR surgery has fallen since fiscal year 1984 from "very high" variability to "moderate" variability. KR utilization was shown to be negatively, but not significantly, related to orthopedic surgeon density. Therefore, proposals to modify surgeons' fees or to influence their practice locations may equalize the supply of surgeons, but are unlikely to affect the pattern of KR utilization.

Adult↗

PubMed1996

Discoid meniscus in children: magnetic resonance imaging characteristics.

OBJECTIVE: To describe the magnetic resonance imaging (MRI) appearance and associated abnormalities of discoid menisci in children. PATIENTS AND METHODS: The MRI findings for a total of 30 knees (in 20 children ranging in age from 4.5 to 16 [mean 9] years) in which discoid meniscus had been diagnosed were reviewed and correlated with clinical symptoms and arthroscopy findings. RESULTS: The symptoms, bilateral in 5 patients and unilateral in 15, included pain in 15 knees, snapping or clunking in 8, reduced mobility in 8, locking in 2 and "giving-way" in 2; there were flexion contractures in 2 patients. Five patients had unilateral symptoms but bilateral discoid menisci. The transverse diameter of the meniscus ranged from 18 to 37 mm and the depth from 14 to 36 mm. The lateral meniscal height was significantly greater than the medial meniscal height (p = 0.0001). On T1-weighted and T2-weighted images the meniscal signal was increased heterogeneously in 11 knees, in a central, horizontal, linear fashion in 9, diffusely in 6 and in a partly linear, partly diffuse fashion in 3. Thirteen joint effusions, 10 lateral meniscal tears and 4 meniscal cysts were identified. Eight arthroscopy procedures were performed in six of the children (for seven knees). Discoid meniscus was confirmed in six knees (with one initial false-negative result), tears were confirmed in four, and an additional tear was identified in one; in addition, one meniscus was characterized as Wrisberg type. CONCLUSIONS: Discoid meniscus commonly occurs bilaterally. High intrameniscal signal is found, especially in symptomatic patients. The size criteria for diagnosing this condition in children are similar to those for adults.

Adolescent↗

PubMed1996

Ancrod: clinical indications and methods of use.

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Ancrod↗

PubMed1995

Reported use of strategies by surgeons to prevent transmission of bloodborne diseases.

OBJECTIVE: To determine how often surgeons use strategies to prevent the transmission of bloodborne diseases and what factors are associated with the use of these strategies. DESIGN: Cross-sectional mail survey. SETTING: Secondary and tertiary care teaching hospitals affiliated with the University of Toronto. PARTICIPANTS: Of 539 active surgical staff and residents who were eligible, 503 (93.3%) responded. OUTCOME MEASURES: Current preventive practices, attitudes toward transmission of bloodborne diseases, perceived risk of infection and willingness to adopt preventive strategies. RESULTS: On average, surgeons reported using double- or triple-gloving in 32.2% of procedures, facial protection (including regular corrective eyewear) in 74.2% and goggles or face shields in 19.4%. Use of strategies to prevent sharp injuries, in addition to barrier precautions, was reported by 259 (51.5%) of the respondents. Factors associated with greater use of preventive strategies included resident position, subspecialty, greater number of years in surgical practice and a high perceived risk. Most of the respondents thought that patients should be routinely screened for HIV antibodies before surgery (68.2% [343/503]), that there was too little research into ways to reduce the risk of transmission of bloodborne diseases (55.3% [278/503]) and that there was too little effort on the part of organizations to reduce the risk of transmission (58.8% [296/503]). The perceived lifetime risk was reported to be moderate or high by 191 (38.0%) of the respondents and low or insignificant by 308 (61.2%). In all, 463 (92.0%) indicated a willingness to change the way they performed surgery to prevent transmission of bloodborne diseases. CONCLUSION: Surgeons expressed varying degrees of concern about the transmission of bloodborne diseases and reported infrequent use of preventive strategies. Efforts to reduce the risk of transmission between patients and surgeons will need to include informing surgeons of their personal risk and the availability of preventive strategies, improving the comfort of barrier precautions and minimizing how preventive strategies interfere with surgery.

Adult↗