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PubMed2005

[The role of preoperative hooked-wire localization of occult lesions for early detection of breast cancer].

OBJECTIVES: Nonpalpable small lesions, usually few millimeters in diameter, consist an important problem in the early diagnostics of breast cancer. DESIGN: An aim of this paper was an evaluation of usefulness of preoperative hooked-wire localization of such lesions for the detection of breast cancer. MATERIALS AND METHODS: Material consisted of 131 patients aged 37-77 in whom 132 procedures of preoperative hooked-wire localization were performed. The correlation between the mammographic findings and the cytologic or histologic results were then evaluated, with the histologic results being treated as standard. RESULTS: Histologic examination of the localized lesions revealed benign changes in 71.2%, atypical ductal hyperplasia in 4.6% and cancer in 24.2%. Positive predictive value for mammography was 24%. Significant correlation was seen between the suspicion of cancer in mammography and the histologic results. CONCLUSIONS: Preoperative localization should be used as a method of choice in radial lesions, suspected clustered microcalcifications and after the positive result from SFAB.

Adult↗
PubMed1996

Selection criteria for preoperative endoscopic retrograde cholangiopancreatography in the laparoscopic era.

BACKGROUND: Indicators for cholangiography were originally designed to select patients at risk for common bile duct (CBD) stones for intraoperative cholangiography. OBJECTIVE: To refine these criteria to apply to the much more invasive procedure of preoperative endoscopic retrograde cholangiopancreatography (ERCP). DESIGN: Retrospective review of selection criteria for ERCP in consecutive patients referred over 18 months following the introduction of laparoscopic cholecystectomy. SETTING: Two ERCP units in adjacent teaching hospitals. PATIENTS: Three hundred seventeen patients with gallstones and in situ gallbladders. INTERVENTION: Common bile duct imaging at ERCP. MAIN OUTCOME MEASURES: Abnormalities justifying ERCP. RESULTS: Abnormalities justifying ERCP were found in 66% of patients. This group differed significantly from those with normal ducts, with more being referred with abnormal results of all liver function tests (P < .001), jaundice (P < = .001), a dilated CBD on ultrasound (P < .001), or CBD stones on ultrasound (P < .001). On the other hand, patients with normal ducts were significantly more likely to have been referred with pancreatitis (P = .003) or elevated results of individual liver function tests (P < .001). A logistic regression model using age, presence of jaundice at ERCP, levels of alkaline phosphatase and albumin, and ultrasonography showing dilated ducts or visible CBD stones was found to have a specificity of 75% and a sensitivity of 89%. Past pancreatitis or elevated results of individual liver function tests were not predictive factors. CONCLUSION: The use of such a model rather than individual criteria would improve the selection of patients for preoperative ERCP, optimizing its role in the laparoscopic era.

Adult↗
PubMed2001

Revision total knee arthroplasty: planning, management, controversies, and surgical approaches.

Revision total knee arthroplasty can be a technically challenging procedure fraught with potential complications. In many cases, obtaining adequate exposure is difficult, and failure to do so can directly cause technical errors and complications. Patient-specific systemic comorbidities and anatomic details can further complicate the procedure. Careful preoperative evaluation can help to facilitate optimal results. Furthermore, specific surgical techniques help to improve the surgical exposure and can minimize complications such as wound healing problems, component malposition, and extensor mechanism disruption. All surgeons undertaking these procedures require a thorough understanding of these principles.

Adult↗
PubMed1979

Lower extremity amputation: review of 110 cases.

Very significant morbidity and mortality continue to accompany lower extremity amputations. In this study 90 patients underwent 110 amputations over a 4 year period. The overall complication rate was 40 per cent and the overall mortality rate 12.2 per cent. The patients at greatest risk were the above knee amputees greater than 60 years of age with peripheral vascular disease. Amputation of the lower extremity must be recognized as a major, life-threatening procedure. Careful preoperative evaluation of cardiac, pulmonary, and nutritional status along with efforts to prevent sepsis, pneumonia, pulmonary embolism, gastrointestinal ulceration, and renal failure are necessary if the mortality accompanying these procedures is to be reduced.

Adult↗
PubMed2000

Clinical utility of echocardiography in the management of implantable ventricular assist devices.

BACKGROUND: The high mortality rate of congestive cardiac failure, the cost and complications of cardiac transplantation, and the waiting list mortality rate resulting from donor organ scarcity have encouraged the development of surgical techniques as bridges to transplantation or as long-term palliative therapy. Implantable left ventricular assist devices are now routinely used as such a bridge, and within the REMATCH Trial, as permanent palliative devices in nontransplant candidates. These are mechanical managements with myriad mechanical complications and pitfalls. Echocardiography has been extensively used in our institution to detect and diagnose previously documented and hitherto unencountered complications of these procedures. METHODS AND RESULTS: The role of echocardiography in these procedures, including preoperative patient selection, intraoperative transesophageal echocardiography, and postoperative troubleshooting and late follow-up, is discussed. We describe our clinical echocardiographic approach, which has developed over 91 assist-device procedures. The relative frequency and clinical impact of specific anatomic, physiologic, hemodynamic, and mechanical features are described. New techniques such as the Doppler quantification of assist device inflow obstruction are illustrated, as are the device cannula position, the detection of device valve failure, and the parameters related to the remodeling procedure. CONCLUSIONS: Echocardiography in heart failure surgery has proved to be an invaluable tool in the diagnosis and management of mechanical complications. The experience gained in our institution may serve as an aid to new surgical programs treating these critically ill patients.

Echocardiography↗
PubMed1991

Fine-needle aspiration biopsy of salivary glands.

Between January 1, 1973, and December 31, 1988, the authors or their associates performed 552 fine-needle aspiration biopsies on patients with clinically significant masses of the salivary glands. All patients presented at the Medical College of Virginia Hospitals or Clinics of Virginia Commonwealth University; they were followed for periods ranging from 1 to 16 years. When available, the fine-needle aspiration diagnoses were correlated with histologic diagnoses and long-term patient outcomes. The sensitivity for a neoplasm was 93.3%; the specificity for the absence of a neoplasm was 99%. Diagnostic efficiency was 96.4%, and predictive value of a positive aspiration for a neoplasm was 98.3%. With fine-needle aspiration, surgical excision of salivary gland masses is often unnecessary. In patients with primary and metastatic neoplasms involving the salivary glands, fine-needle aspiration aids the surgeon in mapping the extent of the surgical procedure and in preoperatively preparing the patient. The procedure is cost-effective.

Adolescent↗
PubMed1999

Preoperative risk factors associated with symptomatic pulmonary embolism after total knee arthroplasty.

This retrospective case-control study reviewed 124 consecutive patients undergoing cemented total knee arthroplasty under regional anesthesia for osteoarthritis. Seven (5.6%) patients developed symptomatic pulmonary embolism despite warfarin prophylaxis. Bilateral procedures and preoperative hemoglobin were identified as significant risk factors for the development of symptomatic pulmonary embolism after total knee arthroplasty (hemoglobin > or =14 g/L, odds ratio 2.4, confidence interval [CI] 1.2-4.6, and bilateral cases odds ratio 7.2, CI 1.3-39.6). Additionally, preoperative hemoglobin <14 gm/L was associated with a 98% negative predictive value of developing symptomatic pulmonary embolism with a 14% false-negative rate (sensitivity 85.7%, 95% CI 80-92; specificity 67.9%, 95% CI 60-77; positive predictive value 14%, 95% CI .08-2). These findings indicate preoperative hemoglobin levels should be considered in addition to the usual patient demographics in future thromboembolism studies as a potential risk factor for symptomatic pulmonary embolism.

Anticoagulants↗
PubMed2000

Comparison of visual results in initial and re-treatment laser in situ keratomileusis procedures for myopia and astigmatism.

PURPOSE: To report the results of initial and re-treatment laser in situ keratomileusis procedures for myopia and astigmatism. METHODS: A total of 1161 consecutive inital and retreatment laser in situ keratomileusis procedures in 697 patients performed between September 19, 1996, and June 20, 1998, were retrospectively analyzed. Baseline and postoperative best spectacle-corrected visual acuity, uncorrected visual acuity, spherical and cylindrical refractions, computerized video keratography, and biomicroscopy were measured or performed on each eye. RESULTS: Of 1,071 eyes, 900 (84%) underwent a single-laser in situ keratomileusis procedure, and 171 of 1,071 eyes (16%) underwent one or two re-treatment procedures. The preoperative mean +/- SD spherical equivalent was -5.09 +/- 3.15 diopters (range, -0.75 to -14.38 diopters) and the cylinder was 0.97 +/- 1.09 diopters (range, 0.00 to 3.25 diopters) in the group that underwent a single laser in situ keratomileusis treatment. The preoperative mean +/- SD spherical equivalent was -6.26 +/- 3.04 diopters (range, -1.75 to -12.88 diopters) and the cylinder was 1.53 +/- 1.11 diopters (range, 0.00 to 3.50 diopters) in the group that underwent re-treatment. Before re-treatment, 110 eyes (64.3%) in the group that underwent re-treatment achieved 20/40 or better uncorrected visual acuity and 23 eyes (13.5%) achieved 20/25 or better. Three months after re-treatment, 155 eyes (90.6%) achieved 20/40 or better, and 80 eyes (46.8%) achieved 20/25 or better. In the single-procedure group, uncorrected visual acuity at 3 months revealed 20/40 vision or better in 856 eyes (95.1%) and 20/25 vision or better in 572 eyes (63.6%). In this study group, 23.6% of eyes with a preoperative spherical equivalent greater than -6.0 diopters underwent re-treatment compared with 11.8% of eyes with a preoperative spherical equivalent of -6.0 diopters or less. CONCLUSIONS: Laser in situ keratomileusis appears to be an effective procedure for mild, moderate, and severe myopia. In eyes with residual refractive error, re-treatment laser in situ keratomileusis procedures can result in good visual outcomes.

Astigmatism↗
PubMed2003

Current issues in pediatric ambulatory anesthesia.

This article summarizes current guidelines in pediatric ambulatory anesthesia and surgery. The reader is provided with our department's current outpatient guidelines at Children's Hospital of Philadelphia and the rationale behind them. Whenever possible, the differences in anesthetic management for the freestanding surgicenter will be discussed. Appropriate patient and procedure selection, preoperative assessment, intraoperative and postoperative considerations, and protocols for follow-up are discussed.

Ambulatory Surgical Procedures↗
PubMed1987

Preoperative parathyroid localization by superimposed iodine-131 toluidine blue and technetium-99m pertechnetate imaging.

A new parathyroid scintigraphic localization study by a dual radioisotope technique using radioiodinated toluidine blue (RTB) for the parathyroids and 99mTc for thyroid imaging is presented. A simple RTB labeling procedure achieving 99% tagging of the 131I-TB was used. The RTB was found to be a highly specific parathyroid radiotracer, consequently enabling superimposition of the delineated thyroid gland over the RTB avid parathyroid foci without a need for subtraction of the thyroid or vascular background. Forty-six patients with primary hyperparathyroidism underwent scintigraphic study prior to cervical (41 patients) or mediastinal (5 patients) exploration and 67 pathological parathyroid glands (34 adenomas and 33 hyperplasias) were excised. On follow-up, serum calcium level returned to normal in all patients. Correlation of the scintigraphic results with the surgical findings disclosed a sensitivity of 93%, with a specificity of 80% and an overall accuracy of 87%. This new simplified and specific RTB scintigraphic method justifies its use as a routine procedure for preoperative parathyroid scintigraphic localization in primary hyperparathyroidism.

Adolescent↗
PubMed2003

The surgical treatment of cancer: a comparison of resource utilization following procedures performed with a curative and palliative intent.

BACKGROUND: Costs associated with the provision of medical care continue to escalate. Therefore, providers must evaluate the cost-effectiveness and benefit to individual healthcare practices. The authors evaluated the immediate and short-term resource utilization needs of patients undergoing surgical intervention with curative or palliative intent. METHODS: Three hundred two patients undergoing surgery with therapeutic intent were observed from the time of admission for intervention until the time of death or until 6 months from the time of the surgical procedure. Surgeons preoperatively identified each case as either curative or palliative in intent. Demographic information, as well as the nature of all interactions with the cancer center, was recorded. RESULTS: Surgeons identified 58 (19%) procedures as palliative and 244 (81%) as curative in intent. Demographic characteristics between the two groups were similar, although recurrent or metastatic disease was more often present in palliative rather than curative patients (P = 0.0078) and palliative intent patients were more likely to have received previous therapy. During the 6-month period, 4690 encounters occurred with the cancer center. The mean number of encounters per patient in each group was similar, although curative intent patients were more likely to have visits with therapeutic intent including chemotherapy administration (P = 0.01), radiation (P = 0.003), or repeat surgical procedures (P = 0.006). In contrast, palliative patients were more likely to be admitted for management of symptoms (P = 0.0001) and had fewer hospital-free days than did curative patients (P = 0.0069). CONCLUSIONS: The average number of encounters for patients undergoing treatment of disease was not significantly different, suggesting that patients undergoing surgery with palliative intent do not require a greater amount of resources than curative intent patients. The nature of the interactions, however, was different, suggesting that resource needs are different and may need to be anticipated in the assessment of how better quality outcomes can be achieved in the palliative surgery setting.

Adolescent↗
PubMed2005

Perioperative management of pedal amputations.

When performing a pedal amputation, proper preoperative, intraoperative, and postoperative care is essential for a successful outcome. This article outlines proper perioperative management for the amputation patient. All patients require appropriate medical management and testing before any surgical procedure; however, preoperative planning specific for the amputation patient also is required to determine the appropriate level of amputation and to provide an optimal result. The surgeon always must remember that patients with more distal amputations have a decreased energy expenditure and better functional outcome compared with their more proximal counterparts. Appropriate psychological counseling and physical rehabilitation also should be initiated as early as possible for the patient to recover fully in a timely fashion.

Amputation, Surgical↗
PubMed1997

Cancellations cut by three-fourths.

A critical pathway of lumbar discectomy has helped Blodgett Memorial Medical Center in Grand Rapids, MI, decrease cancellations by incorporating a preoperative telephone call one to two weeks before surgery. 50% of patients are going home in 23 hours or less. A handful of those are going home the same day as the procedure. The preoperative telephone call includes registration, education, instruction about laboratory tests to be done before the day of surgery, and even discharge planning.

Critical Pathways↗
PubMed1986

Reoperative achalasia surgery.

Forty-six patients with esophageal achalasia required reoperation between January 1970 and January 1986. Three of these patients required a second reoperative procedure, for a total of 49 reoperations. Indications for reoperation were inadequate myotomy, 17; gastroesophageal reflux, 14; concomitant antireflux operation, six; incorrect diagnosis, four; carcinoma of the esophagus, four; megaesophagus, three; and paraesophageal hernia, one. Various procedures were employed at the time of reoperation, including revision of the myotomy, takedown or revision of a previously performed wrap, fundoplication, and resection. Of the 48 patients available for follow-up study over an average postoperative period of 5 years, the condition of 38 (79%) was considered to have been improved by reoperation. The best results were obtained by revision or takedown of a previous wrap (an improvement rate of 88.9%) and radical resective procedures (89% to 100%). We conclude that for good results to be achieved after reoperative achalasia procedures, the preoperative diagnosis must be accurate, the operation should be performed early before the development of megaesophagus, and a short but complete esophagomyotomy must be performed, preferably without the addition of an antireflux procedure. Elimination or revision of a previously performed fundoplication can be expected to be followed by good results. The precise indications for radical resective procedures have yet to be defined clearly, but their wider application to carefully selected patients with postoperative achalasia seems justified.

Adult↗
PubMed1998

Aspects on the actual practice of surgical management of urinary incontinence in Norway and Finland.

OBJECTIVE: To elucidate aspects of the actual practice of surgical management of urinary incontinence in Norway and Finland. METHOD: A questionnaire about preoperative diagnostic procedures, type of surgery, follow-up procedure and number of operations per center and per surgeon per year (1995) was sent to all departments of Gynecology and Obstetrics in Norway and Finland. RESULT: Thirty-one (86%) of the Norwegian and 26 (90%) of the Finnish departments returned the questionnaire. More than 90% of the departments performed preoperative urodynamic evaluation. Burch colposuspension was used by more than 90% of the departments in the two countries. Generally the number of procedures per center and per department was low. Twenty-nine and 12% of the departments respectively did not perform any follow-up after surgery. Only 16% of the Norwegian and 23% of the Finnish centers had controlled results of surgery. CONCLUSION: There seems to be a need for criteria of good clinical practice or a reference program for all steps of surgical management of stress incontinence in order to stimulate the process of quality development of this treatment.

Female↗
PubMed1993

Preoperative evaluation of inferior vena cava involvement secondary to malignant abdominal neoplasms.

The authors report their experience of different imaging techniques (US, CT, MRI, and cavography) used to evaluate inferior vena cava involvement due to abdominal malignant neoplasms. The study is a retrospective analysis of preoperative data on 15 patients of both sexes in comparison with intraoperative and/or pathological findings. All patients underwent ultrasonography, with good results in all the venous segments studied, as for the CT scan; the limitation of both techniques is the unsafe evaluation of venous wall involvement when the neoplastic tissue is confined inside the vessel. The results obtained using MRI seem to be very encouraging, but we only studied three cases with this technique, and so cannot assess the real value of the method. In nine patients we performed inferior cava phlebography: we believe this to be a very reliable exam to demonstrate vessel wall invasion, even if it is a very invasive procedure, its limits being the inability to observe proximal thrombotic extension when the vein is completely obstructed by the tumor. On the basis of their experience the authors suggest a multi-technique imaging diagnostic procedure for preoperative staging with a view to obtaining as much information as possible to correctly program surgical procedure.

Abdominal Neoplasms↗