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PubMed1999

Selection of patients for carotid endarterectomy: the role of ultrasound.

Stroke is the third leading cause of death in the western world and the major cause of disability among the middle aged and elderly populations. Carotid artery stenosis is the single most important risk factor for stroke. The North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial have demonstrated that the risk of stroke is reduced by surgery in patients with high grade stenosis. Carotid plaque morphology also plays an important role; plaques which are ulcerated and echolucent are associated with a higher risk of stroke. Arteriography has long been regarded as the gold standard diagnostic tool for evaluation of carotid artery disease, but it is an invasive and costly technique which carries the risk of potentially serious complications. Doppler ultrasound can provide functional and anatomical information on vessel stenosis and plaque morphology at sub-millimetric resolutions and is an inexpensive and noninvasive tool. Color and spectral Doppler ultrasound are now recognized as the best screening tests for carotid artery stenosis. The evidence for its use as the sole diagnostic imaging modality prior to carotid endarterectomy is examined. The recent availability of ultrasound contrast agents helps to distinguish between pseudo- and true occlusions, improves ultrasound images and should help to reduce operator variability.

Blood Flow Velocity↗
PubMed1999

The risk of breast cancer following reproductive surgery.

Alteration of exposure to ovarian hormones, by eliminating or impairing the function of one or both ovaries, may affect the risk of breast cancer. To assess the relationship between reproductive surgical procedures and breast cancer risk, we conducted a retrospective cohort study involving 524,709 Ontario women who underwent tubal ligation or other salpingectomy, hysterectomy and/or ovariectomy between 1979 and 1993. Data on type and year of surgery were obtained from hospital records and linked with breast cancer diagnoses recorded in the Ontario Cancer Registry. Observed breast cancers were compared with age- and calendar-period expected rates in Ontario. A decreased risk of breast cancer was observed among women who had undergone either hysterectomy (observed/expected [O/E] = 0.87, P < 0.001) or unilateral ovariectomy (O/E = 0.74, P < 0.001). Bilateral ovariectomy and tubal ligation were associated with reduced risk when the surgery occurred before the age of 45 years, and tubal ligation was protective if performed after the age of 54 years. There was no trend in risk with increasing follow-up. Our data support the hypothesis that reduced levels of endogenous oestrogen may be protective for breast cancer in women.

Adolescent↗
PubMed2006

Establishing navigated control in head surgery.

Navigated Control (NC) describes an additional control for a tracked power driven instrument within a preoperatively segmented work space. In head surgery the authors first implemented NC in functional endoscopic sinus surgery (FESS). Recently the feasibility of NC for surgery on the petrosal bone is evaluated. NC in FESS and in petrosal bone surgery may reduce the risk of comorbidity and the time effort compared to the conventional surgical interventions.

Endoscopy↗
PubMedDate not supplied

[Comparative study of 2 antibiotic prophylactic protocols in oncologic surgery of the pharynx and larynx].

The use of antibiotic prophylaxis in oncological pharyngeal and laryngeal surgery has reduced the risk of postoperative wound infection, which decreases morbidity and health-care costs. We report the results of a prospective randomized study in our hospital comparing the effectiveness of two antibiotic protocols, amoxicillin-clavulanate and clindamycin plus gentamicin, both given for 24 hours, in patients who underwent clean-contaminated oncological surgery of the pharynx or larynx.

Amoxicillin↗
PubMedDate not supplied

Current management of extracranial carotid artery disease.

Stroke is the third most common cause of death in the United States. There are approximately 700,000 strokes/year; 80% are ischemic, and 20-30% of ischemic strokes are secondary to carotid disease. Carotid stenosis is traditionally treated by carotid endarterectomy (CEA). Multicenter, randomized, controlled trials have shown that surgery significantly reduces the risk of ipsilateral stroke in patients with severe symptomatic and asymptomatic carotid stenosis. Endovascular techniques for treating carotid stenosis have been developed over recent years. Carotid angioplasty and stenting (CAS) with cerebral protection has become an alternative to CEA for high-surgical-risk patients and the procedure of choice for stenoses inaccessible by surgery. In this review we summarize the existing data regarding the traditional state of management of extracranial carotid artery stenosis and compare these data to a critical analysis of the recent results of CAS.

Angioplasty↗
PubMed2005

Acceptance of prophylactic surgery and chemoprevention of cancer in Singapore - a survey.

INTRODUCTION: In addition to surveillance practices, chemoprevention and prophylactic surgery can reduce the risk of cancer in individuals at high risk. Sociocultural factors may have a role to play in such decision making. Little is known regarding the factors that play a role in decision making in Singapore. MATERIALS AND METHODS: One hundred and two individuals at normal risk completed a questionnaire on the concept of chemoprevention and prophylactic surgery. The results were analysed using the convenience sampling method. RESULTS: Participants were mostly Chinese (94.1%). More than 90% of the respondents answered the section on prophylactic surgery and chemoprevention. Thirty-eight individuals (41.3%) would not consider prophylactic surgery, while 42 (45.7%) would not consider prophylactic surgery now but might consider it in the future. Twenty-five individuals (26.9%) would not consider chemoprevention by taking a medication, 57% would not consider it now but might in the future. CONCLUSION: A cross-sectional public view suggests that medical prophylaxis is likely to be more acceptable to the general public compared to surgical prophylaxis.

Adolescent↗
PubMed1992

Eighteen-year follow-up in the Veterans Affairs Cooperative Study of Coronary Artery Bypass Surgery for stable angina.

BACKGROUND: The 18-year effect of bypass surgery compared with medical therapy on survival, incidence of myocardial infarction, and relief of angina was evaluated in 686 randomized patients with stable angina in the Veterans Affairs Cooperative Study of Coronary Artery Bypass Surgery. METHODS AND RESULTS: The primary treatment comparisons were made according to intent to treat; 44% of the entire medical cohort had bypass surgery during a median follow-up of 16.8 years. Overall 18-year survival rates were 33% for medicine compared with 30% for surgery (p = 0.60). Survival rates for high-risk patients without left main disease, which had shown a significant advantage for surgical therapy up to 11 years, were 23% medicine versus 24% surgery for patients with three-vessel disease and impaired left ventricular function (p = 0.49) and 22% versus 25% for those with multiple clinical risk factors (p = 0.12). For patients with two-vessel disease, who had significantly better survival with medical therapy at 11 years, rates were similar at 18 years in the two treatment groups (34% medicine versus 30% surgery, p = 0.09). Cumulative 18-year myocardial infarction rates (fatal plus nonfatal) were 41% in medical and 49% in surgical patients (13% perioperative infarction rate), p = 0.15. Nonfatal infarction rates were lower with medical than with surgical therapy (32% versus 44%, p = 0.015), but fatal infarction rates were similar (14% medicine versus 13% surgery, p = 0.62). The combined rate of myocardial infarction or death was also lower with medical therapy (75% versus 82%, p = 0.016). In contrast, surgery reduced mortality after myocardial infarction by 35% at 10 years (p less than 0.001) but only by 13% at 18 years (p = 0.09). The percent of medical and surgical patients who were angina-free was 3% versus 22% (p less than 0.001) at 1 year and 4% versus 12% (p less than 0.001) at 5 years compared with rates of 6% versus 5% (p greater than 0.50) at 10 years and 3% versus 4% (p greater than 0.50) at 15 years. CONCLUSIONS: The benefits of coronary artery bypass surgery on survival, symptoms, and postinfarction mortality were transient and lasted fewer than 11 years. The benefits began to diminish after 5 years, when graft closure accelerated. Surgery was effective in reducing mortality only for patients with a poor natural history. Low-risk patients, who had a good prognosis with medical therapy, derived no survival benefit with surgical therapy at any time during the follow-up period. Regardless of risk, surgery also did not reduce the incidence of myocardial infarction or the combined incidence of infarction or death.

Angina Pectoris↗
PubMed2005

Secondary prevention after ischemic stroke. Evolution over time in practice.

BACKGROUND AND OBJECTIVE: An optimal management of vascular risk factors, associated with antithrombotic drugs and carotid surgery when appropriate, reduces the risk of a new vascular event after stroke. Although secondary prevention is not optimal in many patients in practice, the question of whether there is an improvement over time remains unanswered. The aim of our study was to test the hypothesis that secondary prevention measures after cerebral ischemia improve over time. METHOD: We included 123 consecutive patients in 1994, and 125 consecutive patients in 2002, who were admitted to a neurological department for any reason and had had an episode of cerebral ischemia less than 6 years earlier. We compared the groups for the management of arterial hypertension, hypercholesterolemia, diabetes mellitus and smoking. We recorded the values of blood pressure, biological parameters, and presence of antithrombotic therapy, lipid-lowering and anti-hypertensive drugs. Whether patients were properly treated or not, was determined by a comparison between their current treatment and guidelines available when recruited. RESULTS: Prevention was not optimal in 96 of 123 (78%) patients in 1994, and in 77 of 125 (62 %) in 2002. Vascular risk factors were better identified and managed in 2002 than in 1994, especially for hypercholesterolemia. Antithrombotic therapies, statins and antihypertensive drugs, except calcium channel blockers, were more often used in 2002. The proportion of patients in whom arterial hypertension and hypercholesterolemia were identified was higher in 2002, but the proportion of patients identified as diabetics remained stable. However, the proportion of patients with blood pressure >140/90 mmHg, glycemia >or = 126 mg/dl, total cholesterol level > or = 240 mg/dl, or being current smokers, were significantly lower in 2002 than in 1994. CONCLUSION: Although most of patients with previous cerebral ischemia did not receive an optimal management of their risk factors in 2002, there was an improvement over an 8-year period.

Aged↗
PubMed2004

[Intragastric balloons--the new hope in bariatry?].

The concept of intragastric space-occupying balloon developed from observations in psychiatric patients with gastric bezoars. Several gastric balloons consisting of different materials were developed. The BioEnterics Intagastric Balloon System (BIB) is a smooth, spherical, silicone elastomer balloon inducing satiety and restricting food intake. The balloon is indicated to induce weight loss in patients before surgery, to reduce the surgical risk, to select the patients for gastric restrictive surgery. Our experience showed that patients who had good results with the balloon they are good candidates for gastric restrictive surgical procedures. There were few complications: balloon intolerance, spontaneous deflation, oesophagitis, gastritis and rarely gastric ulcers. Conclusion is that in selected patients intragastric balloon can be used as effective and safe approach and could be a great help to induce weight loss and to prepare for surgery.

Bariatrics↗
PubMed2000

When to operate in carotid artery disease.

Carotid endarterectomy has proved to be beneficial in the prevention of stroke in selected patients. The procedure is indicated in symptomatic patients with carotid-territory transient ischemic attacks or minor strokes who have carotid artery stenosis of 70 to 99 percent. With a low surgical risk, carotid endarterectomy provides modest benefit in symptomatic patients with carotid artery stenosis of 50 to 69 percent. Platelet antiaggregants and risk factor modification are recommended in symptomatic patients with less than 50 percent stenosis. In the Asymptomatic Carotid Atherosclerosis Study, carotid endarterectomy was beneficial in patients who had asymptomatic carotid artery stenosis of 60 percent or greater and whose general health made them good candidates for elective surgery, provided that the arteriographic and surgical complication rates were low. However, in asymptomatic patients, surgery reduced the absolute risk of stroke by only 1 percent per year.

Carotid Stenosis↗
PubMed2000

Phacoemulsification versus extracapsular cataract extraction in patients with diabetes.

OBJECTIVE: To compare phacoemulsification with extracapsular cataract surgery in patients with diabetes and to identify determinants of postoperative visual acuity. DESIGN: Prospective, randomized, paired-eye trial. PARTICIPANTS: Forty-six patients with diabetes and bilateral cataract. INTERVENTION: Patients were allocated to phacoemulsification surgery with silicone intraocular lens to one randomly determined eye, and extracapsular cataract surgery with 7-mm polymethylmethacrylate intraocular lens to the other. MAIN OUTCOME MEASURES: Logarithm of minimum angle of resolution visual acuity (logMAR VA), incidence of clinically significant macular edema (CSME), retinopathy progression, indices of anterior segment inflammation, and incidence of capsulotomy. RESULTS: Compared with eyes undergoing phacoemulsification, eyes managed with extracapsular surgery had more anterior chamber cells (P = 0.0004) and flare (P = 0.007) 1 week after surgery and a higher incidence of posterior synechiae (P = 0.04) and intraocular lens deposits (P < 0.0005) in the first postoperative year. The need for posterior capsulotomy was greater in eyes undergoing extracapsular surgery (16 of 46 vs. 5 of 46, P = 0.01). No difference in incidence of postoperative CSME, progression of retinopathy, or development of high-risk proliferative retinopathy was identified between techniques (P = 1.0, 0.8, and 0.2). Median 1-year logMAR VA was worse in eyes undergoing extracapsular surgery (0.08 vs. 0.06, P = 0.02), especially in those with retinopathy (0.14 vs. 0.08, respectively; P = 0.01). The presence or absence of CSME at the time of surgery was the most significant determinant of 1-year logMAR VA in regression models for both extracapsular (P = 0.0004, R2 = 0.45) and phacoemulsification groups (P < 0.00005, R2 = 0.46). CONCLUSIONS: Phacoemulsification is associated with better postoperative VA, less postoperative inflammation, and less need for capsulotomy than extracapsular cataract surgery in patients with diabetes. However, with both techniques, the principal determinant of postoperative VA appears to be the presence or absence of CSME at the time of surgery. Early intervention, reducing the risk that unrecognized CSME is present at the time of surgery, may be more critical to outcome than choice of surgical technique.

Aged↗
PubMed2003

[Technique for vascular management under thoracoscopic surgery].

Vascular injury is the most life-threatening complication under thoracoscopic surgery. To reduce the risk of vascular injury, knowledge of the anatomy of the pulmonary artery, variations in its branching, skillful techniques and careful maneuver are necessary. Pulmonary artery being adherent to bronchus is dangerous to dissect under thoracoscopy, so it is better to convert to open thoracotomy. A3 of the left upper lobe is occasionally injured during dissection. It is a safety technique for using vascular stapler under thoracoscopic surgery. Stapler leader can allow the passage of a stapler to encircle the vessel.

Female↗
PubMed1997

Role of a 10-Gy boost in the conservative treatment of early breast cancer: results of a randomized clinical trial in Lyon, France.

PURPOSE: To define the role of a 10-Gy boost to the primary tumor in the conservative treatment of early infiltrating breast carcinoma treated by limited surgery and radiotherapy. PATIENTS AND METHODS: Between 1986 and 1992, 1,024 women with early breast carcinoma (< or = 3 cm in diameter) were treated by local excision, axillary dissection, and conventional 50-Gy irradiation given in 20 fractions over 5 weeks and then randomly assigned to receive either no further treatment or a boost of 10 Gy by electrons to the tumor bed. The median follow-up time was 3.3 years as of September 1994. The occurrence of telangiectasia was reported, and the patients were asked to evaluate the cosmetic result. RESULTS: At 5 years, 10 patients of 521 who had received the boost (Kaplan-Meier estimate of local relapse rate, 3.6%) and 20 of 503 who had received no further treatment (Kaplan-Meier estimate of local relapse rate, 4.5%) had developed a local recurrence (P = .044). After adjustment for the main prognostic variables, the relative risk was still significantly lower for the boost group (0.3; range, 0.12 to 0.95). The boost group had a higher rate of grade 1 and 2 telangiectasia (12.4% v 5.9%), but no difference was seen between the two treatment arms in the self-assessment score for the cosmetic result. CONCLUSION: Delivery of a boost of 10 Gy to the tumor bed after 50 Gy to the whole breast following limited surgery significantly reduces the risk of early local recurrence, with no serious deterioration in the cosmetic result. Additional follow-up evaluation will be required to assess the long-term results.

Adult↗
PubMed1998

Somatosensory evoked potential monitoring during positioning of the patient for posterior fossa surgery in the semisitting position.

OBJECTIVE: Midcervical flexion myelopathy is a rare but well-known complication of posterior fossa surgery. To reduce the risk, we routinely used somatosensory evoked potential (SSEP) monitoring during positioning of the patient. METHODS: Fifty-five consecutive patients were operated on for posterior fossa lesions in the semisitting position via a median (5 patients) or a lateral (50 patients) suboccipital approach. During positioning, monitoring of SSEPs by stimulation of the tibial nerve (T-SSEP) as well as by stimulation of the median nerve (M-SSEP) was established. In the case of pronounced SSEP changes, the head was repositioned. Surgery was started after SSEP recordings were unchanged as compared to the baseline investigation. RESULTS: Effective monitoring was possible in all cases. Whereas M-SSEP recordings showed no changes while placing patients in the sitting position, T-SSEP recordings were altered in 14 cases (25%). In cases using the midline approach, SSEP changes were never so pronounced to require repositioning of the head. Head flexion and rotation resulted in significant changes of T-SSEP recordings in eight patients (14.5%), requiring repositioning. In two cases, an amplitude loss was noted. In only two of these eight patients were M-SSEP recordings markedly changed. SSEP recordings after repositioning disclosed recovery of spinal cord function. In no patient were clinical signs of myelopathy observed postoperatively. CONCLUSION: We observed a high incidence of pronounced changes of T-SSEP recordings when the patient's head was flexed and rotated for lateral suboccipital craniotomy in the semisitting position. Despite the low specificity monitoring of T-SSEPs during positioning of the patient for posterior fossa surgery, the semisitting position is strongly recommended.

Adolescent↗
PubMed2002

Evidence-based surgical wound care on surgical wound infection.

Surgical wound infection is an important outcome indicator in the postoperative period. A 3-year prospective cohort epidemiological study of 2202 surgical patients from seven surgical wards across two hospitals was carried out using gold standard surveillance methodology. This involved following patients up as inpatients and postdischarge surveillance to 30 days by an independent observer. The results led to the development of a mathematical model for risk of clean, elective surgical wound infection. Risk of surgical wound infection was increased by smoking, higher body mass index, presence of malignancy, haematoma formation, increasing numbers of people in theatre, adherent dressing usage, and higher times to suture removal (P<0.05). The results show that this type of surveillance is an effective way of collecting accurate data on wound infection rates. It was noted that patient care practices affected the surgical wound infection rate and the surveillance was used to facilitate the adoption of evidence-based practice, through recommendations for clean surgery, to reduce the risk from extrinsic risk factors for wound infection. As a result of the implementation of this evidence-based practice there was a significant reduction (P<0.05) in the clean wound infection rate.

Bandages↗
PubMed2006

Optimum view distance for laparoscopic surgery.

BACKGROUND: Proper visualization of the surgical field without fatigue is essential in laparoscopic surgery and reduces the risk of iatrogenic injuries. One of the important factors influencing visualization is the viewing distance between the surgeon and the monitor. This was the subject of the current investigation. METHODS: For this study, 14 surgeons participated in experiments designed to determine two working distances from a standard 34-cm (14 in. diagonal) cathode ray tube (CRT) monitor: (a) the maximum view distance permitting small prints of a near vision chart to be identified clearly by sight, (b) and the minimum view distance (of a standard resolution chart) just short of flicker, image degradation, or both. The range of the monitor optimal working distance for laparoscopic surgery was extrapolated from these data sets. RESULTS: The maximum view distance allowing identification of detail averaged 221 cm (range, 166-302 cm). The mean minimal view distance short of flicker/image degradation was 136 cm (range, 102-168 cm). The coefficient of variation for the two view distances was almost identical (18% vs 17%, respectively), and a frequency histogram confirmed the normality of the two data sets. Thus, for most surgeons, the extrapolated monitor view distances for laparoscopic surgery using a 14-in. diagonal (34-cm) monitor range from 139 to 303 cm (57-121 in.) for maximal distance viewing and from 90 to 182 cm (36-73 in.) for close-up viewing (i.e., a monitor optimal working distance ranging from 90 to 303 cm (36-121 in.). CONCLUSIONS: For most surgeons operating from a 14-in. diagonal CRT monitor, both the maximal and minimal (close-up) view distances are individually variable, but the surgeon should never be farther than 3 m (10 ft) or less than 0.9 m (3 ft) from the monitor. However, within limits, the maximal view distance increases with increasing monitor size. The limit for close-up distance is 0.9 m, irrespective of monitor size.

Clinical Competence↗
PubMed2006

A phase III randomized trial of postoperative pelvic irradiation in Stage IB cervical carcinoma with poor prognostic features: follow-up of a gynecologic oncology group study.

PURPOSE: To investigate, in a phase III randomized trial, whether postoperative external-beam irradiation to the standard pelvic field improves the recurrence-free interval and overall survival (OS) in women with Stage IB cervical cancers with negative lymph nodes and certain poor prognostic features treated by radical hysterectomy and pelvic lymphadenectomy. METHODS AND MATERIALS: Eligible patients had Stage IB cervical cancer with negative lymph nodes but with 2 or more of the following features: more than one third (deep) stromal invasion, capillary lymphatic space involvement, and tumor diameter of 4 cm or more. The study group included 277 patients: 137 randomized to pelvic irradiation (RT) and 140 randomized to observation (OBS). The planned pelvic dose was from 46 Gy in 23 fractions to 50.4 Gy in 28 fractions. RESULTS: Of the 67 recurrences, 24 were in the RT arm and 43 were in the OBS arm. The RT arm showed a statistically significant (46%) reduction in risk of recurrence (hazard ratio [HR] = 0.54, 90% confidence interval [CI] = 0.35 to 0.81, p = 0.007) and a statistically significant reduction in risk of progression or death (HR = 0.58, 90% CI = 0.40 to 0.85, p = 0.009). With RT, 8.8% of patients (3 of 34) with adenosquamous or adenocarcinoma tumors recurred vs. 44.0% (11 of 25) in OBS. Fewer recurrences were seen with RT in patients with adenocarcinoma or adenosquamous histologies relative to others (HR for RT by histology interaction = 0.23, 90% CI = 0.07 to 0.74, p = 0.019). After an extensive follow-up period, 67 deaths have occurred: 27 RT patients and 40 OBS patients. The improvement in overall survival (HR = 0.70, 90% CI = 0.45 to 1.05, p = 0.074) with RT did not reach statistical significance. CONCLUSIONS: Pelvic radiotherapy after radical surgery significantly reduces the risk of recurrence and prolongs progression-free survival in women with Stage IB cervical cancer. RT appears to be particularly beneficial for patients with adenocarcinoma or adenosquamous histologies. Circumstances that may have influenced the overall survival differences are considered.

Adenocarcinoma↗
PubMed1990

Surgery offers no more than medical treatment in the management of transient ischaemic attack.

This paper debates the motion that 'Surgery offers no more than medical treatment in the management of transient ischaemic attack' (TIA). The arguments in support of this motion are that surgical treatment has a high morbidity and mortality, and that even the investigation of patients by angiography prior to surgery entails a risk of stroke; that TIA is a marker of generalised vascular disease, and that medical treatment can reduce the incidence of stroke after TIA. The counter arguments are that TIA is associated with an increased risk of stroke and this risk can be reduced by surgery; that recent surgical results show an acceptable complication rate, and that modern methods of investigation permit accurate non-invasive assessment of patients at risk of stroke.

Aspirin↗