Preoperative management of the oral surgical patient in disease.
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Disease Management↗
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Use of a picture archiving and communications system (PACS) and computed plain radiography in preoperative planning.
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Adolescent↗
Outcome analysis of endoscopic III ventriculostomy.
A retrospective chart review was performed on 54 patients who had undergone endoscopic III ventriculostomy (E3V) in the past 6 years. Patient charts were reviewed to establish age at the time of operation, sex, preoperative diagnosis, preoperative shunt procedures, success or failure of the E3V, duration of success, and complications. Success of an E3V was determined by the resolution of preoperative symptoms and avoidance of a CSF shunt. The most recent clinic visit with adequate documentation of signs and symptoms of hydrocephalus was used as the last date of follow-up. The overall success rate was 74%. Children over the age of 3 years with an acquired CSF obstruction had a significantly greater probability of successful treatment (P=0.05). Younger children, especially those with hydrocephalus attributable to obstruction of the arachnoid villi, as in intraventricular hemorrhage (IVH), were less likely to benefit from E3V.
Adolescent↗
Noninvasive imaging of insulinomas and gastrinomas with endoscopic ultrasonography and somatostatin receptor scintigraphy.
BACKGROUND: Classic morphological techniques are of limited value for imaging endocrine duodenopancreatic tumors, and invasive procedures such as intraarterial stimulation are often used. Two noninvasive procedures, endoscopic ultrasonography (EUS) and somatostatin receptor scintigraphy (SRS), were recently described with promising results. METHODS: In this study we correlated the results of preoperative EUS (n = 34) and SRS (n = 30) with operative findings in patients with histologically proven insulinoma (n = 20) or gastrinoma (n = 21). RESULTS: The sensitivity and positive predictive value (PPV) of EUS were respectively 77% and 94% for pancreatic tumors (insulinomas and gastrinomas), 40% and 100% for duodenal gastrinomas, and 58% and 78% for metastatic lymph nodes. The sensitivity and PPV of SRS for insulinoma were 60% and 100%, respectively. In patients with gastrinoma, the sensitivity and PPV of SRS were respectively 25% and 100% for pancreatic gastrinomas, 72% and 100% for duodenal gastrinomas or periduodenal metastatic lymph nodes, and 67% and 80% for liver metastasis. In patients with multiple endocrine neoplasia, neither one of the two techniques detected all tumors. Overall sensitivity of combined EUS and SRS was 89% for insulinoma (n = 9) and 93% for gastrinoma (n = 14). CONCLUSIONS: EUS and SRS for gastrinomas and insulinomas should be considered as the initial preoperative imaging procedures and may render invasive procedures unnecessary for most patients.
Adolescent↗
Physical diagnosis of the multiple-ligament-injured knee.
Knee dislocations and related knee trauma represent dramatic orthopedic injuries. The severity and spectrum of injury may not be immediately evident to the clinician. A high index of suspicion for associated neurovascular involvement must be maintained throughout the initial care of the patient. In anticipation of ligament repair and reconstruction, a preoperative MR imaging study supplemented by an examination under anesthesia allows for an accurate assessment of the pattern and severity of ligament injury. With this knowledge the surgeon is able to prepare properly for surgery and create appropriately placed surgical incisions to afford adequate exposure of all injured structures.
Humans↗
Autogenous fat injection for vocal fold atrophy.
Autogenous fat augmentation for glottic insufficiency has been used previously in patient treatment regimes. However, relatively little information is currently available regarding the effectiveness of fat injection for patients with vocal fold atrophy who have complete glottal closure (VFACGC). This paper compares, in retrospect, the efficiency of fat injection after surgery in patients with VFACGC (n=21). The perceptual acoustic and phonatory functions and videolaryngostroboscopic data were evaluated before and after fat augmentation was performed on 13 patients. Mean follow-up time was 9.5 months. Fifteen patients displayed excellent results, four experienced post-procedure failure, and two were unavailable for follow-up analysis. The majority of VFACGC patients (71%) also suffered from muscular tension dysphonia (MTD) preoperatively. The procedure also resolved the MTD in half (54%) of the patients in this study. Perceptual rating showed significant improvement in grade, roughness and breathiness (P<0.05). The videolaryngostroboscopic rating showed significant improvements in vocal fold edge linearity (P<0.01), vocal fold vibration amplitude and mucosal wave excursion (P<0.05). VFACGC is commonly misdiagnosed as MTD and is, therefore, unresponsive to speech therapy that is targeted to the latter. Fat injection is an effective autogenous implant and should be considered as an option in the treatment of patients with VFACGC. Although fat re-absorption was identified as a problem, repeating the procedure could be considered to minimize the effect of such.
Adipose Tissue↗
Surgery in hemophilia. The general view: patient selection, timing, and preoperative assessment.
Although often overlooked, the life of the patient with severe hemophilia is characterized by both intermittent and chronic pain. Bleeds into joints and muscles cause extensive pressure on sensory nerves and, following recurrent bleeds, joint destruction, and synovial reaction is accompanied by constant pains that are frequently mistaken for further bleeding. The orthopedic surgeon may break the vicious cycle of chronic synovitis by excising inflamed and hypertrophic synovium or severely damaged cartilage and adjacent bone ends, and implanting an artificial joint. Numerous technical solutions are now available and orthopedic surgery is increasingly on offer to those hemophilia patients who, since childhood, have been victims of insufficiently treated bleeds because no or limited treatment was available, and because the concept of prophylaxis had not yet been developed. Nonetheless, orthopedic surgery in patients with hemophilia requires much more effort and planning than surgery in non-hemophilic patients. In this overview, we will address issues related to surgery in hemophilic patients, as well as some practical issues related to the timing of surgery, preoperative testing, perioperative hemostasis, and patient rehabilitation.
Hemophilia A↗
Preoperative determination of the surgical procedure for hepatectomy using technetium-99m-galactosyl human serum albumin (99mTc-GSA) liver scintigraphy.
Technetium-99m-diethylenetriaminepentaacetic acidgalactosyl human serum albumin (Tc-GSA) is a new liver scintigraphy agent which binds to the asialoglycoprotein receptors. We evaluated the preoperative assessment for hepatectomy using Tc-GSA liver scintigraphy. Ninety patients with hepatocellular carcinoma were admitted for elective hepatectomy. Tc-GSA scintigraphy was conducted after the intravenous injection of Tc-GSA, and maximal removal rate of Tc-GSA (GSA-Rmax) was calculated using a radiopharmacokinetic model. Measurement of GSA-Rmax, conventional liver function, and 15-minute retention rate of indocyanine green (ICGR15) was carried out preoperatively. The relationships between liver functions, histological activity index (HAI), ICGR15, and GSA-Rmax values were estimated. A significant correlation was obtained between GSA-Rmax and ICGR15 (r = .534, P < .0001). Preoperative discrepancies between GSA-Rmax and ICGR15 values were seen in 15 patients. In these cases, the GSA-Rmax values correlated well with the total HAI scores (r = .595, P < .02), but no significant correlation was seen between the ICGR15 and HAI scores. Two patients died of postoperative liver failure within 2 months of the operation. These two patients were found to have severe discrepancies between their preoperative GSA-Rmax and ICGR15 values. We concluded that GSA-Rmax might be useful for selecting candidates for hepatectomy and that extended hepatectomies (di- and tri-segmentectomy) are high-risk surgical procedures in the case of low GSA-Rmax scores (below 0.35).
Adult↗
[Xanthogranulomatous pyelonephritis].
Based on literature and own case the entity of xanthogranulomatous pyelonephritis is reviewed. In particular are discussed the difficulties of the preoperative diagnostic procedures and the differential diagnosis.
Diagnosis, Differential↗
Improved demonstration of endometrial polyps and submucous myomas using saline-enhanced vaginal sonohysterography.
We evaluated the efficacy of enhancing the vaginal ultrasound visualization of endometrial polyps and submucous fibroids using the intrauterine saline as a contrast medium in 30 women with abnormal uterine bleeding. Each woman underwent evaluation with a standard vaginal sonogram and then a saline-enhanced sonogram. For the latter, sterile saline was instilled into the uterine cavity with a soft polyethylene, intrauterine insemination cannula to enhance the visualization of intrauterine structures. The patients subsequently underwent hysteroscopy and endometrial sampling. The saline-enhanced vaginal sonohysterogram clearly improved the visualization of submucous myomas and endometrial polyps in 17 of 19 women. In four women it showed no evidence of myomas or polyps. In seven of the earlier procedures in this series, filling of the uterine cavity was too poor to use the results. We conclude that vaginal saline sonohysterogram is simple yet safe, and is a valuable preoperative diagnostic procedure.
Adult↗
Repair of pectus excavatum. Anesthetic considerations.
The majority of patients undergoing pectus excavatum repair can be safely anesthetized with routine clinical preoperative evaluation and chest radiography. Electrocardiography, echocardiography, arterial blood gas, and pulmonary function tests should be reserved for patients with suspected coexisting conditions, such as mitral valve prolapse, skeletal abnormalities, Marfan's syndrome, and pulmonary disease. The choice of surgical repair and the advisability of placement of an epidural catheter or intercostal blocks for perioperative pain management should be discussed with the surgical team. Postoperatively, patients should be carefully monitored for signs of tension pneumothorax and pneumonia.
Anesthesia↗
The utility of preoperative laboratory testing in general surgery patients for outpatient procedures.
The utility of obtaining routine preoperative laboratory (lab) screening tests was evaluated for a 1-year period in general surgery clinic patients undergoing ambulatory surgical procedures at a teaching hospital. This study sought to determine whether those lab tests not indicated by patient history or physical examination would identify abnormalities that might influence perioperative care of the ambulatory surgical patient or predict perioperative complications. The charts of 142 patients undergoing 155 procedures were reviewed. A total of 300 tests were ordered, with 92 (30.6%) being abnormal. Of the 125 tests indicated, 54 (43.2%) were abnormal, whereas in those lab tests not indicated, 38 (21.7%) were found to be abnormal. In four instances, an abnormal lab test (4 out of 300) result was clinically significant (1.3%), causing cancellation of the surgical procedure in two cases (both indicated lab tests) and diagnosis of urinary tract infection in two patients (both routine urinalyses). Forty-eight of the 142 patients had no preoperative lab tests ordered (34%), with no perioperative complications resulting. Patient charges totaled $15,725 for all lab tests ordered, with $8,573 in charges attributed to those tests not indicated. If lab tests for all general and subspecialty surgical outpatients had been ordered as dictated by patient medical history and physical examination rather than by either routine or by arbitrary criteria, our medical facility could have potentially reduced patient charges by more than $400,000 in the year reviewed, assuming a 52.4 per cent savings as noted above, with no expected adverse outcomes.
Adolescent↗
Preoperative assessment and discharge planning for older adults undergoing ambulatory surgery.
Based on this survey, the prevalence of chronic illness and disability in older adult patients with respect to current ambulatory surgery practices is worrisome, especially the fragmentation of patients' care as they progress from the decision to undergo procedures, to preoperative assessment, to postoperative discharge. Ambulatory surgery unit nurses, case managers, surgeons, and office staff members must work together to better optimize time and resources. As baby boomers age, the number of older adults undergoing ambulatory surgery will increase. It is essential for ASU staff members to be cognizant of the special needs of older adult patients. Timeliness, patient education, and appropriate coordination and follow-up of care are important ingredients to successfully plan care for older adult patients undergoing ambulatory surgery. Nurses can play a pivotal role in this success.
Activities of Daily Living↗
Postoperative utilization of critical care services by cardiac surgery: a multicenter study in the Canadian healthcare system.
OBJECTIVES: To describe patterns of critical care services used after cardiac surgery and to evaluate whether variations in the process of care influence outcome. DESIGN: Multicenter, prospective study. SETTING: A convenience sample of four cardiac surgical units: three in university-affiliated (teaching) hospitals and one in a nonteaching regional referral center. PATIENTS: A "consecutive sample" of 335 patients after cardiac surgery in four hospitals. INTERVENTIONS: Data were collected regarding all cardiac surgery patients admitted to the critical care units in the four test hospitals. MEASUREMENTS AND MAIN RESULTS: The critical care unit and hospital lengths of stay and survival were followed. The Therapeutic Intervention Scoring System (TISS) was used to assess the intensive care unit (ICU) interventions used during the first 24 hrs in the ICU and for the final 24 hrs before discharge from the ICU. The severity of illness on admission was assessed using the Acute Physiology and Chronic Health Evaluation (APACHE) scoring system. For patients having similar procedures (e.g., aortocoronary bypass and nonaortocoronary bypass procedures) and with similar outcome (mortality/total hospital length of stay), we found significant differences in the pattern of ICU resource utilization among hospitals. Significant (p < .05) differences in unit length of stay were related to varying factors in different hospitals. In hospital unit A, the type of procedure and preoperative chronic health status influenced unit length of stay (aortocoronary bypass 2.8 +/- 1.7 days; nonaortocoronary bypass 8.7 +/- 8.9 days) because length of stay was different for differing procedure groups. In hospital unit B, the critical care management system and lack of step-down (intermediate care) unit availability resulted in an increased unit length of stay for aortocoronary bypass patients (5.1 +/- 4.5 days) as compared with the other units (mean ICU lengths of stay of 2.8, 2.3, and 3.0 days, respectively). Unit B kept patients for monitoring purposes and had a reduced need for critical care nursing on the day of discharge (TISS = 7.5 +/- 5.5) as compared with the other units (mean TISS scores of 27.4, 23.2, and 21.5). CONCLUSIONS: Significant differences exist among hospitals in the same healthcare system in the utilization of critical care services for cardiac surgery. In spite of these differences, for similar patient "input," the outcome (mortality and hospital lengths of stay) appeared similar. Assessments of utilization of critical care must focus on more detailed specific issues than unit length of stay, and must include factors such as availability of intermediate care areas, the unit management system, chronic health status, and the operative procedures performed, if a utilization management process is to effect improved resource use in critical care.
Canada↗
Tibial sesamoid planing procedure: an appraisal of 26 feet.
The authors present their findings upon evaluation of 26 feet that had undergone a tibial sesamoid planing procedure. A preoperative method of radiographic evaluation is also presented. The subjective success rate was determined to be 88.8%, whereas the objective success rate was 76.9%, and a successful procedure was performed on feet with a first metatarsal declination angle not exceeding 8 degrees. It was also determined that the apparent postoperative changes in the hallux abductus and intermetatarsal angles were 0.73 degrees and 0.6 degrees, respectively. The authors believe this procedure does not significantly alter the biomechanics of the first metatarsophalangeal joint postoperatively.
Adolescent↗
Arthroscopic management of the arthritic elbow: indications, technique, and results.
Twenty-four patients with painful restricted motion of the elbow joint because of an arthritic process were treated with an arthroscopic modification of the open Outerbridge-Kashiwagi procedure. Average preoperative flexion was to 90 degrees (range 60 degrees to 140 degrees), and average extension loss was -40 degrees (range -5 degrees to -60 degrees). The average total arc of motion was 50 degrees. The procedure consisted of arthroscopic debridement, partial resection of the coronoid and olecranon processes, and fenestration of the olecranon fossa. The radial head was excised arthroscopically in 18 of the 24 patients. All patients were reexamined 24 to 60 months after operation (mean 32 months). All patients had a significant decrease in pain as described by a visual analog scale (preoperative 8.2; postoperative 2.2). Average flexion was to 139 degrees (range 95 degrees to 145 degrees), and average extension loss was -8 degrees (range 0 degree to 15 degrees). The average arc of motion was 131 degrees, an improvement of 81 degrees. Arthroscopic ulnohumeral arthroplasty provides satisfactory results in terms of pain control and improved motion. The complication rate is comparable to those reported in series of open ulnohumeral arthroplasties. This procedure seems to be a valuable adjunct in the management of the arthritic elbow, serving as an intermediate step between nonoperative management and elbow replacement surgery.
Adolescent↗
Anatomical variations of the V2 segment of the vertebral artery.
OBJECTIVE: Our goal was to evaluate the incidence of anatomic variations of the V2 segment (from its entrance into the transverse canal to C2) of the vertebral artery. Ignoring such variations during anterior or lateral approach to the cervical spine can lead to inadvertent injury and potentially serious complications. METHODS: We studied the course of 500 vertebral arteries on 200 magnetic resonance imaging and 50 contrast-enhanced computed tomographic scans. RESULTS: The vertebral artery entered the C6 transverse foramen in 93.0% of all specimens. An abnormal level of entrance was observed in 7.0% of specimens (35 courses), with a level of entrance into the C3, C4, C5, or C7 transverse foramen, respectively, in 0.2% (n = 1; 2.9% of all anomalies), 1.0% (n = 5; 14.3% of all anomalies), 5.0% (n = 25; 71.4% of all anomalies), and 0.8% (n = 4; 11.4% of all anomalies) of all specimens. Seventeen (48.6%) abnormalities were right-sided and 18 (51.4%) were left-sided. Thirty-one out of 250 patients (12.4%) had a unilateral anomaly and two had a bilateral anomaly (0.8%). In cases of abnormal entrance into the transverse foramen on computed tomographic images (n = 6), the area of the unfilled transverse foramens was significantly smaller than the contralateral filled foramen (P < 0.0001) and was significantly smaller than the filled foramen of all patients at the same level (P < 0.0001). In five patients (2.0%), the vertebral artery formed a medial loop either into an unusually large transverse foramen whose internal border was medial to the uncovertebral joint or into the intervertebral foramen. CONCLUSION: The incidence of anatomic variations of the vertebral artery V2 segment is high. Potentially dangerous conditions can be detected on preoperative imaging.
Anthropometry↗
Primary aldosteronism. Study of twenty-six operated cases.
A follow-up study of 26 patients operated on for suspicion of primary aldosteronism was made. The preoperative investigative procedures, including serum potassium concentration, urinary aldosterone excretion, and plasma renin activity, could not differentiate between patients with cortical adenomas and those with cortical hyperplasia or normal glands. Preoperative roentgenologic examinations visualized only one third of the adenomas. Altogether 44 of the 52 suprarenal glands had to be explored to reveal the 21 adenomas. Patients with cortical adenoma often became normotensive, in contrast to those with cortical hyperplasia or normal adrenal glands histopathologically. The suprarenal glands were explored from behind according to Nesbit. The complications were few and minor.
Adenoma↗