[Irrigation of vas deferens during vasectomy].
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Adult↗
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Clinical utility of immunoscintigraphy in managing ovarian cancer.
Ovarian cancer spreads to multiple areas of the peritoneal cavity early in the course of the disease. Multiple small foci of tumor are not identified readily with standard preoperative staging procedures. A review of an immunoscintigraphy study of more than 100 women preoperatively staged with 111In-labeled B72.3 (CYT-103) reveals that this technique has a low potential for serious side effects and it can identify miliary spread of ovarian cancer and extra-abdominal metastases. It has the potential to contribute favorably to patient management by detecting occult lesions, may define the extent of tumor as well or better than computerized tomography and may impact on surgical decision-making.
Aged↗
Minimally invasive video-assisted parathyroidectomy: multiinstitutional study.
Unilateral and minimally invasive parathyroidectomies with endoscopic and video-assisted technique have been introduced. Most of these procedures utilize preoperative localization and intraoperative monitoring of parathyroid hormone. There are only a few reports on these procedures. The objective of this study was to evaluate video-assisted parathyroidectomy (MIVAP) for surgery in patients with primary hyperparathyroidism (pHPT). From February 1997 to June 1999 a series of 123 consecutive patients with pHPT at four surgical centers were evaluated. The patients' ages ranged from 18 to 77 years (median 50 years). Preoperatively, sestamibi scintigraphy and ultrasonography for localization were performed for all patients. Selection criteria for a MIVAP procedure excluded patients with negative localization, suspicion of multiglandular disease (MGD) or thyroid malignancy, a large thyroid mass, and prior surgery or irradiation to the neck. MIVAP was performed with a 1.5 cm suprasternal incision; the operation was then done through this incision with a 30 degree 5 mm endoscope and microsurgical instruments with brief CO2 insufflation for adenoma identification. We then proceeded with an open technique through the small incision under video-assistance. Intraoperative monitoring of intact parathyroid hormone (iPTH) assays was used in all patients. Among the 123 patients in whom MIVAP was attempted, the procedure was accomplished in 109 (89%). Conversion to conventional cervicotomy was required in 14 (11%) patients because of failed localization, failure of the iPTH level to fall appropriately, or technical problems. There was no persistent or recurrent HPT during the 3 to 12-month follow-up. Oral calcium replacement for symptomatic hypocalcemia postoperatively was given in 7 (6%) cases. A unilateral transient laryngeal nerve palsy, resolving within 6 months postoperatively, occurred in two (2%) patients. The median hospital stay was 1.5 days (range 0.5-5.0 days). This study showed the feasibility of MIVAP as an alternative surgical treatment for pHPT in a selected group of patients. Further studies are necessary to evaluate the efficacy and rationale of MIVAP compared to other techniques for parathyroidectomy in pHPT patients.
Adenoma↗
Endoscopic third ventriculostomy in the treatment of hydrocephalus in posterior fossa tumors in children.
OBJECT: The purpose of the present study is to assess the effectiveness of endoscopic third ventriculostomy (ETV) in children with hydrocephalus related to posterior fossa tumors. METHODS: Between September 1999 and December 2002, 63 children with posterior fossa tumors were treated at Santobono Hospital in Naples, Italy. Twenty-six patients had severe hydrocephalus. In order to relieve intracranial hypertension before tumor removal, 20 were treated with ETV, and 6 with ventriculo-peritoneal (VP) shunts. Twenty patients with mild hydrocephalus were treated with diuretics, corticosteroid agents, and early posterior fossa surgery, and 17 patients who did not have hydrocephalus were treated by elective posterior fossa surgery. Another 4 ETV were performed in the management of postoperative hydrocephalus. RESULTS: Preoperative ETV procedures were technically successful. One was complicated by intraventricular bleeding. The successful 19 preoperative ETV resolved intracranial hypertension before posterior fossa surgery in all cases. Three of these 19 patients developed postoperative hydrocephalus and were treated by VP shunt insertion after posterior fossa surgery. Out of the 4 ETV performed after posterior fossa surgery, only 2 were successful, both when the shunt malfunctioned. CONCLUSIONS: Endoscopic third ventriculostomy should be considered as an alternative procedure to ventriculo-peritoneal shunting and external ventricular draining for the emergency control of severe hydrocephalus caused by posterior fossa tumors, since it can quickly eliminate symptoms, and hence, can delay surgery scheduling if required. Even though ETV does not prevent postoperative hydrocephalus in all cases, it does protect against acute postoperative hydrocephalus due to cerebellar swelling. In addition, it eliminates the risks of cerebrospinal fluid (CSF) infection related to external drainage and minimizes the risk of overdrainage because it provides more physiological CSF drainage than the other procedures. Since postoperative hydrocephalus is very often physically obstructive, ETV should always be considered a possible treatment procedure.
Child↗
Can screening for genetic markers improve peripheral artery bypass patency?
OBJECTIVE: Three genetic mutations have been associated with an increased risk of thromboembolic events: factor V Leiden R506Q, prothrombin G20210A, and methylenetetrahydrofolate reductase C677T (MTHFR) mutations. The aim of this study was to determine the effect of these mutations on patency of peripheral bypass procedures and preoperative and postoperative thromboembolic events. METHODS: Two hundred forty-four randomly selected volunteers participating in the Veterans Affairs Cooperative Study #362 were tested for factor V Leiden, prothrombin, or MTHFR mutations with polymerase chain reaction. Patients enrolled in the study were randomized to receive aspirin therapy or aspirin and warfarin therapy after a peripheral bypass procedure. The frequencies of preoperative and postoperative thromboembolic events and primary patency (PP), assisted primary patency (APP), and secondary patency (SP) rates were compared among carriers of the various mutations. RESULTS: Fourteen patients (5.7%) were heterozygous for the factor V Leiden mutation, seven (2.9%) were heterozygous for the prothrombin mutation, and 108 (44.6%) were heterozygous and 15 (6.2%) homozygous for the MTHFR mutation. After surgery, patients homozygous for the MTHFR gene mutation had increased graft thrombosis, compared with patients who were heterozygous (33.3% versus 11.1%; P =.01), and lower PP, APP and SP rates (P <.05). Furthermore, patients heterozygous for the MTHFR mutation had fewer graft thromboses (11.1% versus 24.4%; P =.01), fewer below-knee amputations (0.9% versus 7.6%; P =.02), and higher PP, APP, and SP rates (PP, 79.6%; APP, 88.9%; SP, 90.7%; P <.05) compared with wild-type control subjects (PP, 63%; APP, 75.6%; SP, 76.5%; P <.05). CONCLUSION: Patients with either factor V Leiden or prothrombin mutations were not at an increased risk for postoperative graft occlusion or thromboembolic events. Patients heterozygous for MTHFR mutation had a lower risk of graft thrombosis and higher graft patency rates compared with both homozygous and wild-type control subjects. Patients homozygous for the MTHFR mutation had lower graft patency rates compared with patients who were heterozygous, and a trend was seen toward lower patency rates compared with wild-type control subjects. Therefore, screening for the MTHFR gene mutation before surgery may identify patients at an increased risk of graft thrombosis.
Aged↗
[Ureteric and bladder involvement of deep pelvic endometriosis. Value of multidisciplinary surgical management].
OBJECTIVES: To evaluate the clinical features, staging by medical imaging, treatment strategy and results of surgical management of deep pelvic endometriosis with bladder and/or ureteric involvement. MATERIALS AND METHODS: Eighteen cases of ureteric and/or bladder deep pelvic endometriosis (DPE) were treated in our centre between 1996 and 2004. Preoperative data (clinical symptoms, MR imaging), intraoperative data (resection and urinary tract diversion procedures, associated procedures on the genital and gastrointestinal tracts), and postoperative data (histological results, complications, anatomical follow-up by imaging and functional assessment) were reviewed. RESULTS: Urinary symptoms were present in 55% of cases, genital symptoms were present in 83% of cases and gastrointestinal symptoms were present in 46% of cases. A combination of gynaecological and gastrointestinal lesions was demonstrated on imaging in 82% of cases. The mean postoperative follow-up was 16 months (range: 6-36 months). Six patients presented anterior vesical endometriosis. In these cases, the sensitivity and specificity of MRI were 100%. Six partial cystectomies were performed. All corresponded to endometriotic lesions on histological examination. No cases of recurrence of vesical endometriosis were observed. Posterior endometriosis with ureteric involvement was observed in 13 patients (including one with vesical endometriosis). The ureteric lesion was asymptomatic in 8 out of 13 cases (61%). The diagnostic sensitivity of MRI was 92% for posterior nodules, identifying 4 lateral parametrial nodules and 8 median retrocervical nodules. Ureterohydronephrosis was observed in 3 patients with lateral parametrial nodules and 8 patients with median retrocervical nodules, and was bilateral for 3 patients, i.e. 14 dilated renal units. Surgical management consisted of 2 ureteric resections with end-to-end anastomosis, 3 psoas bladder reimplantations, and 9 ureterolyses (8 patients). Two out of 13 patients (15%) with ureteric lesions treated by ureterolysis developed recurrence of the ureteric stricture with upper tract dilatation related to recurrence of the lateral nodule. In 14 patients, genital and/or gastrointestinal resections were associated with the urinary tract procedure. CONCLUSION: Preoperative evaluation of all DPE lesions is based on MRI with reconstruction images of the ureter in the presence of urinary tract lesions. Systematic ureteric stenting prior to surgical dissection of the pelvic wall is recommended in patients with posterior nodules and in the case of partial cystectomy for anterior nodules when the ureteric meati are adjacent to the lesion. Ureteric reimplantation onto a psoas hitch bladder must be performed when the DPE lesions are extensive and partly resected or invade the ureteric wall. The frequency of associated lesions (urinary, gynaecological gastrointestinal) justifies a multidisciplinary surgical approach.
Adult↗
Red cell apheresis in autologous preoperative blood donation.
Preoperative autologous blood donation (PAD) is a commonly used technique for elective surgical procedures with a predictable blood loss. The conventional method is to collect one unit whole blood weekly several times within the shelf-life of red cell concentrates. Erythrapheresis with the Haemonetics cell separator MCS-3p or plus makes it possible to collect two units of red cells in one single session and with this option the time interval and operation can be prolonged to three weeks to improve erythropoiesis. 295 patients, who were scheduled for hip replacement or knee endoprothesis were evaluated retrospectively calculating the net profit of red cells after donating two units of red cells by erythrapheresis. The median net profit of red cells was 140 ml red cells but with a wide range. The patients who profit most of PAD were those with a predonation hct below 42% who had net profits up to 300 ml red cells due to an increased erythropoiesis, which compensate for the withdrawal of the red cells. Thus erythrapheresis with the Haemonetics MCS-3p or Haemonetics MCS plus is recommended for patients with a predonation hct lower than 42% and who can be scheduled for PAD at least 3 weeks before operation when two units of red cells are the target for PAD.
Adult↗
[Preoperative care in ocular surgery].
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Eye↗
Preoperative irradiation and the Assai procedure.
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Humans↗
The usefulness of computer-aided karyometric examination in preoperative differentiation of follicular neoplasms of the thyroid gland.
Fine-needle aspiration biopsy (FNAB) is the most important procedure in preoperative diagnosis of thyroid neoplasms. However, routine cytological examination is insufficient for differentiation between follicular adenoma and follicular carcinoma. Therefore, we decided to assess the usefulness of karyometric analysis in the examination of aspirates from these neoplasms. Morphometric analysis was performed with the use of the computer system for karyometric measurements--"Karyometry Manager" ver. 1.2. We examined cytological smears derived from 26 patients. In 10 of them a nodular goitre was diagnosed in both cytological and histopathological examinations. In the other 16 patients, "follicular neoplasms" were found in cytological examination. These proved to be follicular adenomas (8 cases) and follicular carcinomas (8 cases) on histopathological examination. The following morphometric parameters were measured in 100 nuclei per smear: volume, intersection area, perimeter, convexity coefficient and shape coefficient. We found that: 1) the mean volume and the mean intersection area of thyrocyte nuclei from follicular carcinomas were significantly (p < 0.001) greater than those of nuclei from adenomas or nodular goitres; 2) the mean perimeter of thyrocyte nuclei from follicular carcinomas was significantly greater than the mean perimeter of thyrocyte nuclei from follicular adenomas (p < 0.025) and nodular goitres (p < 0.001); 3) the mean nuclear area of thyrocytes from follicular adenomas was significantly greater than that of thyrocytes from nodular goitres (p < 0.05). Our results show that karyometric analysis can be useful in cytological differentiation of follicular neoplasms.
Adenocarcinoma, Follicular↗
[Preoperative study of the good condition of nerve neurotizers].
In traumatic injury of the brachial plexus, neurotization of peripheral nerves of the hand with different nerve donors is indicated at the preganglionary level in order to restore motor function. This communication describes a procedure for preoperatively determining the state of the nerves to be neurotized. This procedure evaluates the, state of the estimated nerve donors and presents a means of planning in advance the way of performing an operation aimed at recovering the lost motor functions, by considerably reducing the time of the operation.
Arm Injuries↗
Surgery of large retrochiasmatic craniopharyngiomas in children.
From 1981 to 1988, 24 patients with craniopharyngiomas were operated at the Neurosurgical Clinic of the City Hospital of Hannover. Eleven patients were females and 13 males. The median age was 39 years. Ten patients were 20 years of age or younger at the time of surgery. Among these there were four patients who had large (more than 3 cm in greatest diameter), prevalently retrochiasmatic tumors. They represent 40% of the patients up to 20 years of age. Their age ranged from 8 to 17 years; they were all females. Two patients presented with increased intracranial pressure secondary to hydrocephalus, one patient with decreased vision, and one patient presented with seizures. One patient had been previously operated twice elsewhere. A preoperative shunting procedure was necessary in two patients (in one it was bilateral). All patients were preoperatively evaluated with enhanced and nonenhanced computerized tomography (CT) and with angiography. The major tumor diameter was 4 cm or more in three patients and between 3 and 4 cm in one patient. All tumors were prevalently retrochiasmatic. Three tumors extended to the level of the middle clivus. The tumor was approached subfrontally in two patients and subfrontotemporally in two patients. There was no operative mortality. No patient was neurologically worse postoperatively. All patients required hormonal replacement. Adjuvant therapy was not given. All four patients are clinically and CT recurrence free 5 and 20 months and 3 and 4 years after the surgery.
Adolescent↗
Endovascular repair of nontraumatic ruptured thoracic aortic pathologies.
Endovascular repair of ruptured infrarenal abdominal aortic aneurysms (AAA) is receiving increased attention as the number of experienced users increases. Development of thoracic aortic stent grafts has lagged behind infrarenal advancements because of the reported prevalence of disease. In a few centers, however, the experience in performing thoracic stent graft procedures is quite substantial, such that endovascular therapy has been applied to ruptured thoracic aortic pathologies even though data remain limited and this novel therapy remains controversial. We report our combined experience with endovascular repair of ruptured thoracic aneurysms (RTA) and ruptured thoracic dissections (RTD). One hundred eighty-four thoracic stent graft procedures at the University of North Carolina (UNC) and Union Memorial Hospital (UMH) were reviewed and those patients undergoing RTA or RTD repair from January 1, 2000 to December 31, 2003 identified. Patients having procedures for elective repair or aortic transections were excluded from the analysis. Patient presentation, preoperative condition, procedural variables, mortality, and morbidity were examined. Seventy-four percent of the collective procedures were undertaken in high-risk patients (UNC, 38 of 40; UMH, 99 of 144). Twenty-two patients (8.7%; UNC, n = 6; UMH, n = 16) underwent treatment for either an RTA (n = 11) or an RTD (n = 11). The average age of this cohort was 66.5 +/- 15.6 years and the average aneurysm diameter was 73.1 +/- 31.4 mm. The mean duration of symptoms prior to repair was 103.1 +/- 122 hr, influenced primarily by transport times and device availability. Stent graft exclusion was accomplished in 100% of patients with a procedural mortality of 0%. Commercial Talent devices were used in 19 patients (86.4%) and AneuRx device was used in 1 patient (4.5%). In the remaining two (9.1%) patients hand-made devices constructed of Gianturco stents and Dacron fabric were used because of active hemorrhage and lack of appropriate device sizes. Operative time was 135.5 +/- 48.5 min and was associated with an average blood loss of 242.0 +/- 232.4 cc. Thirty-day mortality was 45.5% (RTA, 27.3%; RTD, 63.6%; p = 0.099). Length of stay in the intensive care unit was 6.1 +/- 7.9 days and the mean hospital stay was 11.7 +/- 10.6 days. Major complications were present in 54.5% of RTA (cardiac, 1; pulmonary, 3; cardiovascular accident, 2; spinal cord ischemia, 2; pulmonary embolism, 1), and 81.2% of RTD (multisystem organ failure, 7; pulmonary, 1; common femoral artery injury, 1) but not statistically different between groups. There were only two late complications (cardiac death, endoleak-Ia, 1) that occurred during the mean follow-up of 12.5 +/- 11.3 (range, 1-32) months. These results indicate that endovascular repair of ruptured thoracic pathologies can be accomplished with an acceptable morbidity and mortality. There were no immediate procedural mortalities and complete exclusion was accomplished in all patients. Most postoperative complications arose from preexisting medical conditions and were not procedure related. The benefit of endovascular repair of ruptured thoracic aortic pathologies is promising.
Aged↗
Intraoperative biochemical localization of insulinomas by quick radioimmunoassay.
In patients with organic hyperinsulinism, intraoperative determination of insulin concentrations in veins draining the pancreas might help localize the tumor. We have developed a radioimmunoassay measuring insulin within 30 minutes. At operation, blood samples are taken at various sites in the splenic, superior mesenteric and portal veins for insulin determinations. In all six patients, the highest insulin concentrations correlated with the site of the tumor. Also, small insulinomas less than 1 cm in diameter could be found. In one patient the tumor appeared to secrete mainly proinsulin. By this procedure we hope to avoid blind distal resection of the pancreas and possibly invasive preoperative diagnostic procedures.
Adenoma, Islet Cell↗
Obstetric infection control in a developing country.
In Ghana, infection has been identified as a major cause of birth-related mortality. Results of a 2-month observation of infection control practices among Ghanaian obstetric nurses and midwives indicated that most personnel did not practice basic rules of asepsis. Problems included frequent breaks in technique, inadequate sterilization and disinfection, and repeated exposure to large amounts of blood and vaginal secretions. Supplies were limited and, even when available, not always used appropriately. The situation in developing countries is different from that in the United States. Therefore, an observational needs assessment is essential to plan relevant and practical measures for change.
Cesarean Section↗
[Aspects of preoperative management of biliary surgical procedures].
Difference between open cholecystectomy and laparoscopic cholecystectomy are described. General preparations and pre-operative work up in Austria, Switzerland, Germany and East German quality assurance study at compared. The importance of antibiotic and thrombembolic prophylaxis increased.
Antibiotic Prophylaxis↗
Warm heart surgery: a prospective comparison between normothermic and tepid temperature.
Due to concerns about complications from normothermic core temperature during cardiopulmonary bypass, we initiated a prospective randomized study of 200 consecutive patients. In one group (group A), both the heart and the body temperature were kept at 37 degree C. In the second group (group B), both the body and myocardial temperature were allowed to drift down to 34 degree C. There were no differences between these two groups in age, sex, preoperative numbers of elective, urgent, emergent, redo patients, or coronary artery bypass (CAB), valve, CAB/valve procedures. Their preoperative neurological, pulmonary, renal, and vascular disease status were similar. Preoperative EF was 53% in group A (100 patients) and 52.5% in group B (100 patients). Group A required more volume (p = 0.001) and had less urine output (p = 0.03) during and post bypass. Group A required more phenylephrine hydrochloride (p = 0.05) and had more difficulty managing blood pressure. Strokes and renal failure necessitating dialysis occurred more often in group A but without statistical significance. More difficulties occurred in the normothermic (37 degrees C) group and cardioprotective effects of warm heart surgery may remain intact at 34 degrees C. Mild "drifted/tepid" hypothermic heart surgery could be a better and safer procedure.
Body Temperature↗
Freedom from atrial arrhythmias after classic maze III surgery: a 10-year experience.
OBJECTIVES: We studied the persistence of favorable outcome, the occurrence of new atrial arrhythmias, and sinus node dysfunction in patients who underwent the maze III procedure. METHODS: Preoperative, in-hospital, and follow-up data of 203 patients who underwent the maze III procedure between June 1993 and June 2003 were collected. A total of 139 patients underwent the maze procedure for lone atrial fibrillation, and 64 patients underwent the maze procedure and concomitant cardiac surgery. RESULTS: There was no 30-day postoperative mortality. During a mean follow-up of 4.0 +/- 2.6 years, 12 patients (6%) died (2 cardiac related). At the end of follow-up, freedom from supraventricular arrhythmias was 80% for the lone atrial fibrillation group and 64% for the concomitant atrial fibrillation group. Freedom from stroke during follow-up was 100% in the lone atrial fibrillation group and 97% in the concomitant group. Multivariate analysis revealed that rhythm at 1-year follow-up (P < .001; odds ratio 9.56, 95% confidence limits 3.92-23.31) and preoperative left atrium dimension (P = .028; odds ratio 1.06 for every millimeter, 95% confidence limits 1.01-1.12) were predictors of success at the end of follow-up. CONCLUSIONS: This study shows that the favorable results of the maze III procedure in terms of freedom from supraventricular arrhythmias persist in most patients for at least 4 years.
Arrhythmias, Cardiac↗