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PubMed1981

Cornea pseudoguttata: a clinical and histopathologic description of endothelial cell edema.

Cornea guttata is a well-recognized corneal condition that is characterized by localized thickenings of Descemet's membrane. When these lesions disrupt, the regular endothelial mosaic, dark spots are seen in specular reflection. This same clinical appearance can be present during short-term episodes of iritis and corneal inflammation. Since it disappears with resolution of the inflammation, true cornea guttata (thickening of Descemet's membrane) obviously does not occur. Three cases of this transient clinical entity occurred. Production of iritis and corneal inflammation in rabbits with the use of bovine serum albumin and cautery resulted in the same transient appearance of dark spots, which interrupted the normal endothelial mosaic seen in specular reflection. Scanning and transmission electron microscopy of the cornea "pseudoguttata" disclosed transient endothelial cel edema.

Adult↗
PubMed1983

Histopathology of corneal neovascularization.

We have developed an experimental model for the quantitative examination of the kinetics of the inflammatory cell response to thermal corneal injury. Using this model, we found a considerable difference in the type of inflammatory cell response to vasculogenic (peripheral) and nonvasculogenic (central) thermal cautery of the cornea. We found that infiltration of the corneal stroma with polymorphonuclear leukocytes preceded the growth of blood vessels in this model. This quantitative model will be useful in future studies of the role of inflammatory cells in different models of corneal neovascularization, and may provide quantitative evidence of how known inhibitors of corneal neovascularization exert their effect.

Animals↗
PubMed1985

The histopathology of corneal neovascularization. Inhibitor effects.

With the use of a previously described model of corneal neovascularization induced by thermal cautery, we examined the effects of inhibitors on both the incidence of corneal neovascularization and the degree of inflammatory cell response. Three known inhibitors of corneal neovascularization, 1% prednisolone acetate, indomethacin, and 0.3% flurbiprofen, were studied and the results were compared with those in saline-treated controls. As expected, corneal neovascularization, preceded by conjunctival and corneal polymorphonuclear leukocyte (PMNL) infiltration, occurred in all control animals. Corneal neovascularization did not occur in any of the inhibitor-treated eyes. Histopathologically, both conjunctival and corneal PMNL counts in the treated eyes were markedly reduced compared with controls. These findings are consistent with the hypothesis that inflammatory cells, particularly PMNLs, are closely associated with the initiation of corneal neovascularization.

Animals↗
PubMed1998

Septal perforation repair with acellular human dermal allograft.

BACKGROUND: Connective tissue autografts are commonly used as interpositional grafts between septal flaps in the repair of septal perforations. The most common graft materials used include temporalis fascia and pericranium, both of which are accompanied by donor site morbidity, do not provide septal bulk, and are exceedingly thin and difficult to manage. OBJECTIVE: To study the use of an acellular human dermal allograft (AlloDerm, LifeCell Corp, The Woodlands, Tex) as a connective tissue interpositional graft in septal perforation repair. SETTING: Private facial plastic surgery and reconstructive practice of 1 of the authors (R.W.H.K.), Houston, Tex, and the private and university practice of another author (H.F.), Alexandria, Egypt. PATIENTS: Twelve consecutive patients with septal perforation who received the acellular dermal allograft constituted this evaluation. The causes of the septal perforations were previous nasal surgery, previous nasal cautery, or cocaine use by the patient. DESIGN: Interposition grafting between mucoperichondrial flaps for septal perforation repair was accomplished with decellularized human dermal grafts. Follow-up periods ranged from 3 to 14 months. MAIN OUTCOME MEASURES: The repair was considered successful when, on postoperative examination at 3 months, the right and left mucoperichondrial flaps were entirely healed. From the experience of 1 author (R.W.H.K.) with the repair of more than 75 septal perforations, no perforation that was healed at 3 months broke down at a later date, unless trauma or cocaine use occurred after the operation. An outcome was considered acceptable but nondesirable if a perforation was still present after the operation but the number and severity of the patient's symptoms were reduced and the perforation was considerably smaller than before the operation. RESULTS: Eleven of the 12 patients had successful outcomes with complete closure of their perforations. The 1 remaining patient had an acceptable result but incomplete closure; his initial perforation of 3 cm was reduced to 5 mm, making him asymptomatic after surgery. CONCLUSION: Acellular human dermal grafts can be used as connective tissue interpositional grafts in the repair of septal perforations with success rates similar to the use of temporalis fascia, mastoid periosteum, or pericranium. One distinct advantage is the absence of donor-site morbidity. In addition, this graft material is thicker and easier to place and suture and may give more substance to the repaired septum.

Adult↗
PubMed2003

Microdissection needle tonsillectomy and postoperative pain: a pilot study.

OBJECTIVE: To determine whether microdissection needle cautery for tonsillectomy results in decreased postoperative pain when compared with standard electrocautery. DESIGN AND SETTING: A randomized prospective study of 2 groups of young children in an academic pediatric otolaryngology practice. SUBJECTS: Forty-two healthy children between the ages of 4 and 12 years. INTERVENTION: The 42 children were randomly assigned to 2 groups: in group A, the tonsillectomy was performed with standard monopolar electrocautery tip at 20 W; in group B, the microdissection needle was used at 8 W. The same surgeon performed each tonsillectomy. Other aspects of the procedure were constant, including patient positioning, intraoperative injection of 0.25% bupivacaine hydrochoride (Marcaine), a weight-appropriate dose of steroids, and the use of postoperative antibiotics. OUTCOME MEASURES: The subjective measure of postoperative pain was a questionnaire based on a standard visual analog scale ranging from 0 to 10. More objective measures included the doses of pain medications consumed and the tolerance of oral intake. RESULTS: There was no statistical significant difference in the amount of intraoperative hemorrhage between groups (P>. 01). Operative time was on average 3.2 minutes longer in group B (11 minutes vs 7.8 minutes). The postoperative pain as measured by the visual analog scale was significantly different on days 3, 4, and 5 in group B (P<.05). This difference in pain correlated to differences in the number of doses of pain medications used on the same days. There was no statistically significant difference between the 2 groups concerning the amount of fluids tolerated (P>.01). CONCLUSIONS: Without any increase in complications, subjective and objective measurement showed that the use of the microdissection needle resulted in significantly less postoperative pain by day 3.

Anesthetics, Local↗
PubMed2006

Tubal tonsil hypertrophy: a cause of recurrent symptoms after adenoidectomy.

OBJECTIVES: To assess the incidence of symptomatic tubal tonsil hypertrophy (TTH) after adenoidectomy and to attempt to differentiate the clinicoradiographic presentation of TTH from that of recurrent or residual adenoid. DESIGN: Retrospective case series review. SETTING: Pediatric otolaryngology practice in a tertiary care hospital. PATIENTS: The charts of all patients scheduled to undergo revision adenoidectomy or nasopharyngeal examination under anesthesia over a 5-year period in 1 pediatric otolaryngologist's practice were reviewed. MAIN OUTCOME MEASURE: Presence of TTH in patients with recurrent symptoms after previous adenoidectomy. RESULTS: Forty-two patients were identified, 24 of whom satisfied the established criteria of recurrent symptoms after previous adenoidectomy. Ten (42%) of these patients were identified as having TTH. The average age at presentation was 7 years 2 months, at an average time interval of 4 years 2 months after adenoidectomy. The comparative incidence of recurrent or residual adenoid was 54%. The symptomatic manifestations of TTH included nasal obstruction, obstructive sleep disorder, rhinosinusitis, recurrent otitis media, and otitis media with effusion. Preoperative radiographic evaluation was not useful in distinguishing TTH from recurrent or residual adenoid; nasopharyngoscopy appears to have better diagnostic potential. Thermal ablation with suction cautery was therapeutically effective. CONCLUSIONS: Tubal tonsil hypertrophy is a significant clinical entity as a cause of recurrent symptoms after adenoidectomy. The study patients demonstrated the entire spectrum of signs and symptoms seen in patients with adenoid hypertrophy. Operative nasopharyngeal examination is required to definitively distinguish TTH from recurrent or residual adenoid.

Adenoidectomy↗
PubMed2006

Microdebrider tonsillotomy vs electrosurgical tonsillectomy: a randomized, double-blind, paired control study of postoperative pain.

OBJECTIVE: To examine whether microdebrider intracapsular tonsillotomy (MT) results in less postoperative pain compared with electrosurgical extracapsular tonsillectomy (ET). DESIGN: Prospective, randomized, double-blind, matched pair, clinical trial. SETTING: Specialty care hospital. Patients Twelve male (48%) and 13 female (52%) children aged 5 to 15 years, with obstructive tonsillar hyperplasia were randomized to have one tonsil removed by MT and the other by ET. INTERVENTIONS: An angled endoscopic microdebrider was used to perform MT, and ET was performed by standard monopolar cautery technique. Parents and children were blinded to the side of MT and ET. Children rated the pain 0 to 5 by side using the Faces Pain Scale-Revised. Blinded data collection was via telephone daily for 2 weeks by a study nurse. MAIN OUTCOME MEASURES: Primary: postoperative pain as recorded by Faces Pain Scale-Revised; secondary, presence or absence of otalgia and postoperative bleeding. RESULTS: Twenty-two children (88%) had tonsillectomy and adenoidectomy, while 3 children (12%) had tonsillectomy alone. On postoperative days 1 to 9, children reported significantly less pain on the MT side compared with the ET side (paired t test; P<.01). By postoperative days 10 to 14, the difference between sides disappeared. Twenty children (80%) reported otalgia, and it was always unilateral. For those children reporting otalgia, there was a 100% correlation between the side of otalgia and the side of ET. There was no posttonsillectomy bleeding among the 25 children. CONCLUSION: Microdebrider intracapsular tonsillotomy is significantly less painful compared with electrosurgical ET in children undergoing surgical intervention for obstructive tonsillar hypertrophy.

Adenoidectomy↗
PubMed1982

Microsurgical approach to the temporomandibular joint. A new horizon.

The operating microscope has revolutionized many surgical procedures. To my knowledge, this article records for the first time, pioneering microtechniques for exploring and reconstructing the temporomandibular joint. Determination of pathologic conditions and observation of temporomandibular joint function-dysfunction are dramatic and rewarding. Precision surgery using microinstruments, microneedles, microdrills, and bipolar cautery allows accuracy of technique that previously was impossible. Two representative case presentations illustrate patient treatment, microsurgical technique employed, and clinical results obtained.

Adult↗
PubMed1989

Microscopic endonasal surgery of the paranasal sinuses and the parasellar region.

The anatomic principles and operative techniques currently applied to functional endoscopic endonasal surgery have allowed for significant refinements in another approach to regional pathology that uses the operating microscope, newly designed sinus instruments, and a self-retaining nasal speculum system. The main benefits of this method are the superb widefield stereoscopic vision and the distinct freedom to work bimanually. Additionally, direct bipolar cautery of bleeders is afforded while use of the observer tube or video allows for excellent teaching. The precise nature of this surgery affords less fear of serious complications in the treatment of periorbital, paranasal sinus, and parasellar diseases. We describe technical aspects of the surgery and associated complications in 219 patients treated from 1984 to 1987.

Chronic Disease↗
PubMed1990

Electrodissection tonsillectomy.

A prospective, double-blind study was undertaken to compare the technique of removing tonsils using cold dissection with selective cauterization vs electrocautery dissection. The length of the procedure, blood loss, degree of pharyngeal pain, otalgia, and incidence of postoperative hemorrhage was recorded for 106 consecutive patients. In addition, our experience in performing the electrodissection tonsillectomy in 2431 patients is reviewed. Electrodissection tonsillectomy is a safe and effective procedure that offers several advantages over that of cold dissection using selective cautery.

Double-Blind Method↗
PubMed2001

Robotically assisted laparoscopic cholecystectomy: a pilot study.

HYPOTHESIS: Since the advent of laparoscopic surgery in 1987 and the introduction of robotics into medicine in 1991, medical technology has advanced to robotic applications in performing surgery. In our study, we investigated the feasibility of performing simple laparoscopic maneuvers and laparoscopic cholecystectomy using a robotic surgical system. DESIGN: The study used a ZEUS robotic system (Computer Motion Inc, Goleta, Calif), consisting of 3 interactive robotic arms fixed at the operating table and remotely controlled by the surgeon. After initial training, using a bench model and 3 isolated porcine livers to perform cholecystectomy, 7 female pigs underwent robotically assisted laparoscopic cholecystectomy. The surgeon, seated at the console, manipulated the 3-mm laparoscopic instruments and performed the surgery. RESULTS: Robotically assisted laparoscopic cholecystectomy was accomplished in all 7 pigs, with a mean operative time of 46 minutes (range, 30-62 minutes). There were no complications. The mean time to setup of the robotic system decreased from 30 minutes to 14 minutes. All the robotic maneuvers were performed without any particular difficulties, and the movements were stable, accurate, and reliable, with good control. CONCLUSIONS: Our preliminary experimental study showed that robotically reproduced laparoscopic maneuvers, such as tying, suturing, dissection, clipping, and cautery, seemed to be as accurate and as fast as maneuvers made without robotics. We conclude that our initial experimental and animal study confirmed the feasibility of robotically assisted laparoscopic cholecystectomy. Further reports are needed to show that robotics can be used for clinical applications in surgery.

Animals↗
PubMed1977

Brunner gland adenoma of the duodenum: resection through the fiberoptic endoscope.

We present a case of polypoid adenoma of the Brunner glands of the duodenum. The patient had upper gastrointestinal bleeding. Correct diagnosis of a polypoid mass in the first portion of the duodenum as the cause of bleeding was made, and the lesion was resected endoscopically via an endoscope, using a cautery snare. To our knowledge this is the first reported case of resection of a Brunner gland adenoma with endoscopy, and we hope to encourage the use of this technique for removal of polypoid lesions of the upper gastrointestinal tract.

Brunner Glands↗
PubMed1977

An alternative to hemorrhoidectomy.

This report presents a retrospective review of 670 patients who underwent 3,208 rubber band ligations for internal hemorrhoids. Complications after banding were limited to pain and bleeding. Mild to moderate discomfort occurred in 32 patients (4.8%), while pain severe enough to limit activity occurred in only four patients (0.6%). Slight bleeding was noted in 19 patients (3%), and was severe in nine (1%). Of the latter, only two required hospitalization and cautery, while the remainder subsided on bedrest at home. Banding is discussed in comparison to sclero-therapy, anal dilation and cryohemorrhoidectomy, as well as operative hemorrhoidectomy, and is found to offer not only safety, but major advantages with regard to comfort, convenience, and cost.

Hemorrhoids↗
PubMed1978

Condyloma. A new epidemic.

Condyloma acuminatum of the anus is an increasingly frequent disease that may require a combination of therapies. Large bulky lesions can be reduced with topical freezing, cautery, or the scapel. Topical chemotherapy with podophyllum resin can be supplemented with cancer chemotherapeutic agents. Many of these drugs probably act, at least in part, by stimulating a strong local cellular immune reaction. Dinitrochlorobenzene was used to eradicate lesions that had been resistant to treatment with podophyllum resin. 5-Flourouracil was used as a control. All 23 patients studied were initially skin tested with both agents and randomized to either treatment group. All but one of the dinitrochlorobenzene-treated patients had excellent regressions. Immunotherapeutic agents, such as dinitrochlorobenzene, warrant further study as adjuvant therapeutic agents for this disease.

Antineoplastic Agents↗
PubMed1994

Morbidity and mortality following major penetrating liver injuries.

OBJECTIVE: To establish the mortality and morbidity associated with major penetrating liver injuries and to describe the nature and treatment of complications related to these injuries. We postulated that there had been a trend toward less radical initial surgery, as well as an increased utilization of modern imaging techniques in both diagnosing and treating postoperative complications following penetrating liver trauma. DESIGN: A retrospective survey of medical records and radiology files. SETTING: A university trauma center in an urban setting. PATIENTS: Of the 188 patients admitted to our trauma center with penetrating liver trauma between April 1988 and December 1991, 36 had major liver trauma (grades 3 through 5) and are described in this report. MAIN OUTCOME MEASURES: The mortality rate, type of operative treatment, and the nature and treatment of complications for each grade of major liver injury. RESULTS: The mortality rate from major liver injuries was 17%. Surgical techniques employed primarily consisted of the use of hemostatic agents and cautery, simple suturing, direct vessel ligation, and packing. Fifty-two percent of the survivors had major complications related to the liver injury itself, but only two required operative therapy. The remaining patients were successfully treated with interventional radiologic techniques. CONCLUSIONS: The morbidity and mortality following major penetrating liver injuries remain significant. The majority of hepatobiliary complications can be successfully managed without further surgery but require the combined efforts of the surgeon and interventional radiologist.

Abdomen↗
PubMed1997

Malpractice litigation involving laparoscopic cholecystectomy. Cost, cause, and consequences.

OBJECTIVE: To analyze 44 cases of malpractice litigation involving laparoscopic cholecystectomy for cost, cause, and consequences of civil court actions. DESIGN: Survey of national jury verdict reporting services, covering 20 states during the 39-month interval from January 1, 1993, to April 30, 1996. The 44 laparoscopic cholecystectomies were performed during the 40-month interval from February 1, 1989, to June 30, 1992. MAIN OUTCOME MEASURES: Types of injuries leading to litigation, morbidity and mortality from injuries, trial verdicts, and cost of liability payments. RESULTS: The 44 injuries composed 4 main categories of injuries: (1) bile duct, n = 27, 61%; (2) bowel, n = 7, 16%; (3) major vascular, n = 4, 9%; and (4) other, n = 6, 14%. Bowel injuries involved trocar or cautery injury; vascular injuries all involved trocars. There were 7 deaths (16%) overall from either septic peritonitis resulting from bowel injury (4 patients [57%]) or bile peritonitis involving spills or cystic duct leaks (3 patients [43%]). No deaths resulted from injury to main bile ducts. Of the 44 cases, 21 (48%) settled out of court (mean payment, $469,711). Of the remaining 23 cases proceeding to trial, 19 (83%) were defended successfully while 4 (17%) concluded with plaintiff jury verdicts (mean payment, $188,772). CONCLUSIONS: Frequent settlements of cases involving laparoscopic cholecystectomy injuries that are litigated have resulted in a selection of cases of increased defensibility at trial. The high mortality rate from bowel injuries is a new medicolegal finding in laparoscopic cholecystectomies, as expensive to settle (mean payment, $438,000) as laparoscopic cholecystectomy bile duct injury (mean payment, $507,000).

Cholecystectomy, Laparoscopic↗
PubMed1976

Flexible colonoscopy.

Colonoscopy with fiberoptic instruments has opened new vistas in diagnosis and treatment of colonic disease. Such endoscopy requires skill, experience, and judgment to be accomplished readily and safely but permits visual examination of the entire colon and, frequently, the terminal ileum as well. Although in experienced hands colonoscopy may have greater diagnostic accuracy than the barium enema, particularly with respect to colorectal cancer and polyps, the two are complementary modalities and with their combined use an extremely high rate of detection and confirmed diagnosis can be expected. The Beth Israel group introduced the technique of snare-cautery removal of colonic polyps via the colonoscope and has now successfully resected over 2500 such polyps without a single death. This is the largest world experience. Selected polyps can be removed endoscopically as an ambulatory procedure, reducing costs and incapacitation time. Neoplastic polyps often harbor invasive cancer and their extirpation is expected to reduce the incidence of overt colorectal cancer. Colonoscopy and endoscopic polypectomy offers the opportunity to check the rising incidence, morbidity, and mortality related to colorectal cancer.

Adenoma↗
PubMed1980

The treatment of ameloblastoma based on pathologic and anatomic principles.

A number of important factors must be considered in planning the treatment of ameloblastoma. It is essential to distinguish among the three clinical types of ameloblastoma--the intraosseous solid or multicystic lesion, the well-circumscribed unicystic type, and the rare peripheral (extraosseous) ameloblastoma--because they require different forms of treatment. Unicystic ameloblastomas in which the tumor extends into the lumen of the cyst or involves only the cystic lining can be expected to be removed completely by enucleation. This approach, however, is inadequate if the tumor has invaded the periphery of the fibrous connective tissue wall. Ameloblastomas may invade the intertrabecular spaces of cancellous bone but do not invade compact bone, although they may erode it. Ameloblastomas in the posterior part of the maxilla should be treated more extensively than similar lesions in the mandible because of the proximity of the posterior maxilla to vital structures and the difficulty in treating any recurrences. This article discusses the treatment of ameloblastoma based on these pathologic and anatomic considerations and includes brief discussions of the role of cautery, cryotherapy, and radiotherapy.

Ameloblastoma↗