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PubMed1988

[Selective microsurgical therapy in vascular-induced erectile impotence].

Patients with erectile dysfunction should be subjected to a complex and complete diagnostic procedure, including selective pharmaco-phalloangiography and dynamic pharmacocavernosonography only when SKAT has failed and after the exclusion of neurological disorders. Patients being offered these invasive procedures should be highly motivated and willing to undergo surgical correction of the vascular origin of their erectile impotence. If peripheral vascular occlusive disease is found affecting the pelvic arteries, the best operative technique must be selected. In our opinion, this decision should be made intraoperatively after visualization of the dissected dorsal penile vessels. Use of the Doppler probe can be extremely helpful during the operation. Intraoperative findings on the degree of arteriosclerosis and arterial flow can differ from those allowed by preoperative diagnostic procedures. Penile erectile function was restored in seven of nine patients after penile revascularization performed under microsurgical conditions. We used the operative methods described by Virag and Hauri, applying our own modification of the Hauri procedure in two patients. With careful selection of patients and methods it should be possible to resolve individual patients' problems with peripheral occlusion, even though the exact hemodynamic pathology remains obscure.

Adult↗
PubMedDate not supplied

Three-dimensional ultrasound-based navigation combined with preoperative CT during abdominal interventions: a feasibility study.

PURPOSE: Three-dimensional (3D) intraoperative ultrasound may be easier to interpret when used in combination with less noisy preoperative image data such as CT. The purpose of this study was to evaluate the use of preoperative image data in a 3D ultrasound-based navigation system specially designed for minimally invasive abdominal surgery. A prototype system has been tested in patients with aortic aneurysms undergoing clinical assessment before and after abdominal aortic stent-graft implantation. METHODS: All patients were first imaged by spiral CT followed by 3D ultrasound scanning. The CT volume was registered to the patient using fiducial markers. This enabled us to compare corresponding slices from 3D ultrasound and CT volumes. The accuracy of the patient registration was evaluated both using the external fiducial markers (artificial landmarks glued on the patient's skin) and using intraoperative 3D ultrasound as a measure of the true positioning of anatomic landmarks inside the body. RESULTS: The mean registration accuracy on the surface was found to be 7.1 mm, but increased to 13.0 mm for specific landmarks inside the body. CT and ultrasound gave supplementary information of surrounding structures and position of the patient's anatomy. Fine-tuning the initial patient registration of the CT data with a multimodal CT to intraoperative 3D ultrasound registration (e.g., mutual information), as well as ensuring no movements between this registration and image guidance, may improve the registration accuracy. CONCLUSION: Preoperative CT in combination with 3D ultrasound might be helpful for guiding minimal invasive abdominal interventions.

Aortic Aneurysm, Abdominal↗
PubMed2004

Surgical options in the management of falcotentorial meningiomas: report of 13 cases.

BACKGROUND: The primary aim of surgical treatment for falcotentorial meningiomas is gross total excision. The vital surrounding brain structures make this a complex task. Seeking elements that might facilitate presurgical planning we reviewed our surgical records of falcotentorial meningiomas treated during the past 20 years. METHODS: Between 1975 and 1996, in the Neurosurgical Unit at the University of Rome, "La Sapienza," 13 consecutive patients underwent surgery for falcotentorial meningiomas that had been localized on preoperative imaging and confirmed by histology. The surgical approach varied according to the site of the tumor. RESULTS: Nine meningiomas were totally removed and 4 subtotally. Three patients (23.0%), all treated early in the series, died after the operation. Ten patients (76.9%) survived: 3 (23.0%) had postoperative neurologic complications necessitating reintervention, and 7 patients (53.8%) had an uneventful postoperative course. Two of the 4 patients who had subtotal resections had regrowth at 1 year that responded to radiosurgery. CONCLUSIONS: The ideal surgical approach to falcotentorial meningiomas should allow gross total removal and minimum brain retraction while safeguarding the galenic system and other vital neighboring structures. Toward achieving this aim we propose detailed preoperative imaging studies to classify falcotentorial meningiomas according to their site and direction of growth-craniocaudal or anteroposterior-in relation to the cerebellar tentorium.

Aged↗
PubMed2000

Labyrinthine fistula after cholesteatomatous chronic otitis media.

OBJECTIVES: To report on cases of labyrinthine fistula diagnosed in an ear, nose, and throat department and to study the incidence, location, pre- and postoperative symptoms (hearing loss, tinnitus, vertigo, facial palsy), preoperative diagnostic imaging, and surgical treatment of two types of cholesteatomatous labyrinthine fistulae-the extensive fistula that erodes both the bony and membranous labyrinths and the bone fistula that affects only the bony labyrinth. STUDY DESIGN: Retrospective case review. PATIENTS: Fifty-four patients with cholesteatomatous chronic otitis media with labyrinthine fistulae. SETTING: Tertiary referral center. INTERVENTIONS: Diagnosis and treatment. MAIN OUTCOME MEASURES: Clinical, imaging, and surgical correlation of extensive fistulae and bone fistulae. RESULTS: The incidence of labyrinthine fistulae was 7% in all patients who underwent surgery for chronic otitis media. The bone type (66%) is more common than the extensive type (33%). Compared with bone fistulae, the outcome for extensive fistulae is more severe in terms of hearing loss, vertigo, and facial palsy. In terms of preoperative diagnosis, computed tomography imaging ensured early diagnosis in 89% of extensive cases and in 28% of bone cases. For extensive fistulae, the surgical technique was more radical, requiring an open technique in 66% of cases versus 22% of the bone fistulae cases. The most common location is the lateral semicircular canal (61%). CONCLUSIONS: The breach in the membranous labyrinth is consistent with a more aggressive pathology, causing more severe pre- and postoperative symptoms. Preoperative computed tomography is more sensitive for diagnosing extensive fistulae, which also require a more radical treatment.

Adolescent↗
PubMed2006

Assessment of nutritional status and prediction of postoperative liver function from serum apolioprotein A-1 levels with hepatectomy.

BACKGROUND: We investigated the usefulness of apolipoprotein A-1 (apoA) as an indicator of nutritional status, and the correlation of the preoperative apoA level with changes in postoperative liver function following hepatectomy. METHODS: One hundred patients underwent hepatectomy. Serum levels of apoA, prealbumin (prealb), retinol-binding protein (RBP), lectin-cholesterol acyltransferase (LCAT), hyarulonate (HA), indocyanine green dye retention at 15 minutes (ICG), and the receptor index of Tc-GSA scintigraphy (LHL15) were measured at preoperation and on postoperative days (POD) 7 and 14. Partial resection was carried out in 62 cases, segmentectomy in nine cases, and bisegmentectomy in 29 cases. Co-existent liver conditions were normal liver (NL) in 43 cases, chronic hepatitis (CH) in 29 cases, and liver cirrhosis (LC) in 28 cases. RESULTS: In most cases the serum apoA level had decreased on POD 7, and recovered on POD 14. There were no significant differences in the changes of apoA between the individual operative procedures. Although preoperative apoA had almost the same value in the NL, CH, and LC cases, apoA in LC cases on POD 14 was the lowest of all cases. The apoA level showed significant correlations with prealb, LCAT, and HA on POD 14. All cases were divided into two groups (group N: apoA over 91 mg/dl; group L: apoA under 90 mg/dl) based on the preoperative serum apoA level. On POD 14, the ICG, LHL15, and HA of group L were significantly deteriorated compared with those of group L. CONCLUSION: The serum level of apoA reflects the changes in hepatic protein synthetic ability after hepatectomy; therefore, it may be possible to estimate recovery of nutritional status after hepatectomy from serum apoA. Moreover, we can predict postoperative deterioration of liver function from the preoperative apoA level.

Adult↗
PubMed2002

Surgical results in large-angle exotropia.

PURPOSE: This study examines the surgical results of correcting large angle exodeviations in adults who may lack bifixation. The expected results in adults are not to achieve improved fusion but, rather, to construct the alignment. METHODS: A retrospective chart review was conducted of all patients with comitant exodeviation greater than 35 Delta examined and treated by 1 pediatric ophthalmologist between January 1994 and May 1999. Any patients with large A or V patterns, nystagmus, history of botulinum toxin injections for strabismus, paralytic or mechanical cause for strabismus, or use of adjustable sutures were excluded. Charts were reviewed for postoperative alignment. Postoperative results were separated into 3 categories: exodeviation greater than 10 Delta, successful outcome (esotropia<10 Delta, orthotropia, or exodeviation <10 Delta), or esotropia greater than 10 Delta. RESULTS: Sixty-three patients met the inclusion criteria. Their median age at the time of surgery was 18, with a standard deviation of 20. The majority of them had intermittent exotropia that had deteriorated into constant exotropia. Fifty-two patients had bilateral lateral rectus recessions, and 11 patients had recess/resect procedures. Sixty-two percent (39 of 63) had successful outcomes overall. Only 2 patients had overcorrection (esotropia>10 Delta). In patients with deviations greater than 50 Delta, 82% (9 of 11) were undercorrected (exodeviation >10 Delta). CONCLUSIONS: Large-angle exodeviations can be successfully approached with bilateral lateral rectus recessions or recess/resect procedures in preoperative deviations up to and including 50 Delta with a success rate of 71%. In larger deviations, 2-muscle surgery was not as successful (18%, or 2 of 11).

Adolescent↗
PubMed2006

Skin-reducing mastectomy.

BACKGROUND: The authors propose a combined flap technique to reconstruct large and medium-sized ptotic breasts in a single-stage operation by use of anatomical permanent implants. METHODS: The authors enrolled 28 patients fulfilling criteria for skin-sparing mastectomy and presenting with ptotic breasts whose areola-to-inframammary fold distance was more than 8 cm. All reconstructions were performed as a single-stage procedure. After preoperative planning, a large area in the lower half of the breast was deepithelialized according to the conventional Wise pattern. Mastectomy was then carried out. To perform reconstructions, the inferomedial fibers of the pectoralis major muscle were dissected and sutured to the superior border of the inferior dermal flap. An anatomical implant was then inserted into the pouch, which was closed laterally with the previously harvested serratus anterior fascia. Skin flaps were finally closed down to the inframammary fold. RESULTS: The authors performed 30 procedures on 28 patients. The medium size anatomical implants was 433 cc. Twelve women achieved symmetrization in a single stage ending in a symmetric inverted-T scar. The overall complication rate was 20 percent, with four cases (13 percent) complicated by severe, extensive necrosis of the skin flaps requiring implant removal. CONCLUSIONS: Breast cancer treatment must nowadays optimize cosmetic results. This can be accomplished in selected cases by means of a single-stage operation that the authors call "skin-reducing mastectomy." The final scars imitate those of cosmetic surgery. Careful patient selection and improvement in the learning curve may reduce the complication rate.

Abscess↗
PubMed1992

Repeat mediastinoscopy in the assessment of new and recurrent lung neoplasm.

From 1976 to 1990, 140 patients (mean age, 66 years; 91% male) underwent repeat mediastinoscopy as a routine staging procedure. The mean interval between first and second mediastinoscopy was 56 months. Owing to adhesions, 26 repeat mediastinoscopies (18%) were considered incomplete. There was no mortality, and 10 complications did not require interventional therapy. The results were positive in 20 patients, thus avoiding an unnecessary thoracotomy. In 7 patients with negative findings, positive lymph nodes were found at thoracotomy or by transcarinal puncture biopsy. The sensitivity of repeat mediastinoscopy in this series is 74%, and the accuracy 94%. We consider repeat mediastinoscopy a safe and reliable preoperative staging procedure in new or recurrent lung cancer.

Adenocarcinoma↗
PubMed1982

Outpatient termination of pregnancy: experience in a family practice residency.

At the University of Washington Family Medicine Clinic, termination of pregnancy procedures were performed on 260 patients. Their records were reviewed, and an analysis was completed on demographic data, technical procedure parameters, and complication rates during and following the procedure. The majority of patients were not primigravida. Fifteen percent were between six and eight weeks of gestation. Following the procedure, 3.8 percent had excessive bleeding, and 2.7 percent developed endometritis at rates comparable to those found in the obstetrics and gynecology literature. No known perforations occurred. Outpatient termination of pregnancy performed on selected patients in a family practice setting can be a procedure of low morbidity.

Abortion, Induced↗
PubMed1976

[Extragenital diseases in geriatric-gynecological surgical cases].

Of the surgical cases accumulated in 18 departments of Obstetrics and Gynecology in West Berlin from 1960 through 1969 6662 major procedures were performed on women of at least 60 years of age. In 282 cases (4,2%) surgery was carried out for primarily extragenital gynecological disorders: 119 malignant tumors, 16 benign tumors, and 147 other diseases of extragenital orgin. The postoperative mortality of these patients (89 deaths; 29,8%) was markedly higher than that observed for the whole group (7,7%). This difference may have been caused by the greater extensiveness of the underlying disease in the former group as well as the unsatisfactory utilization of preoperative diagnostic procedures found in some instances. The cooperation with surgeons prior to and during surgery may still be improved upon. In 98 patients (1,5%) operative procedures for additional surgical disorders were performed simultaneously. Especially in those cases where additional appendectomies were carried out, it appears that total abdominal hysterectomy and bilateral salpingo-oophorectomy might have been the treatment of choice for the underlying disease.

Age Factors↗
PubMed2006

Maximum motor fusion combined with one-hour preoperative prism adaptation test in patients with acquired esotropia.

PURPOSE: Preoperative prism adaptation and the maximum motor fusion test reduce the risk of postoperative undercorrection, overcorrection, and bifocal requirements in acquired esotropia. The purpose of our study is to determine the efficacy of the maximum motor fusion test followed by a short prism adaptation test in patients with acquired esotropia undergoing bilateral medial rectus muscle recession. METHODS: We undertook a retrospective review of 29 subjects with acquired esotropia without history of amblyopia, previous strabismus surgery, use of bifocals, pattern anisotropia, dissociated vertical deviation, or oblique muscle dysfunction. All subjects underwent bilateral medial rectus muscle recessions based on the distance angle of deviation measured with the maximum motor fusion test followed by prism adaptation test. Alternate prism and cover testing was performed after 1 hour of prism adaptation to determine the angle of deviation for surgical correction. RESULTS: The age at surgery was 4.5 +/- 1 years. The preoperative angle of deviation at distance was 20.4 +/- 4.2(delta). It increased to 36.2 +/- 4.2(delta) after the maximum motor fusion test followed by 1 hour of prism adaptation testing. The final preoperative angle of deviation post motor fusion test-prism adaptation test was significantly larger than the initial angle of deviation (p < 0.0001). The final postoperative deviation at distance was 1.3 +/- 3.3(delta), and 5.2 +/- 1.5(delta) at near. Postoperative follow up was 18 +/- 2.6 months (range, 13-24 months). CONCLUSIONS: The combination of maximum motor fusion and preoperative prism adaptation allowed increased amounts of medial rectus muscle muscle recession, decreasing the risk of postoperative undercorrection without increasing the risk of overcorrection.

Adaptation, Ocular↗
PubMed1994

[Lung resection for lung carcinoma with idiopathic interstitial pneumonia].

Of 12 patients who underwent lung resections for lung cancer with idiopathic interstitial pneumonia (IIP), eight patients survived and four patients died due to acute exacerbation of IIP after the operation. The preoperative values for percent forced vital capacity, predicted postoperative percent vital capacity, percent one-second forced expiratory volume index and serum level of C-reactive protein were significantly different between the group of patients who survived and that of having died. Three days after the operation, the percentage of lymphocytes among leukocytes and serum level of lactate dehydrogenase in the two groups were both significantly different. These findings showed that the operative strategy for patients with lung cancer and IIP needs specifically careful consideration for operative procedure, and preoperative serum levels of C-reactive protein and postoperative lactate dehydrogenase and the percentage of lymphocytes in leukocytes would be useful in evaluation of the severity of IIP.

Adenocarcinoma↗
PubMed2000

Preoperative embolization of upper cervical cord hemangioblastoma concomitant with venous congestion--case report.

A 16-year-old male presented with a large, solid hemangioblastoma located in the upper cervical cord manifesting as hyperactive reflexes, subtle weakness, and diminished position sense in all extremities. Neuroimaging studies indicated venous congestion due to arteriovenous shunt through the tumor. Preoperative embolization was accomplished without morbidity, and resulted in marked devascularization of the tumor and elimination of an early filling vein. Four days after embolization, the tumor was totally excised without excessive intraoperative bleeding. His neurological deficits gradually improved after surgery. Preoperative embolization is a valuable adjunct to surgical excision of large intramedullary hemangioblastomas, especially those associated with arteriovenous shunt, as cord dysfunction related to venous congestion and the risk of torrential intraoperative bleeding are reduced.

Adolescent↗
PubMed2006

Asymmetry of the height of the ethmoid roof in relationship to handedness.

The aim of this work was to study the handedness differences in the height of the right and left ethmoid roofs. Hand preference was assessed using the Edinburgh Handedness Inventory. The height of the right and left ethmoid roofs was measured with computerised tomography (CT). The incidence of persons who had a lower ethmoid roof on the right side was significantly greater among right-handers than among left-handers; the incidence of persons who had a lower ethmoid roof on the left side was significantly greater among left-handers than among right-handers; and right and left ethmoid roofs were equal in all ambidextrous subjects. The relationship between the asymmetric ethmoid roofs and handedness may result from the right or left embryonic craniofacial region being smaller in the right- or left-handed subjects. This is particularly important in the light of the high degree of variability in the ethmoid roof, and even between the right and left sides in a given individual. Preoperative awareness of a patient's unique sinus anatomy may help prevent iatrogenic injury to the surrounding vital structures during ethmoid sinus surgery (ESS).

Adolescent↗
PubMed2003

Significance of fornix atrophy in temporal lobe epilepsy surgery outcome.

BACKGROUND: Previous magnetic resonance imaging (MRI) studies have shown concurrent fornix atrophy in a large proportion of patients with hippocampal atrophy. The contribution of the fornix as an independent preoperative determinant of surgical outcome is unknown. OBJECTIVE: To evaluate the contribution of the fornix as a determinant of surgical outcome in patients with preoperatively determined temporal lobe epilepsy. METHODS: We selected 78 patients who had undergone anterior temporal lobectomy for intractable temporal lobe epilepsy at the University of Alabama at Birmingham Epilepsy Center during a 24-month period. All patients underwent standard presurgical investigations and intracranial investigations when needed. Magnetic resonance imaging volumetric studies were performed prior to surgery using previously published techniques. Patients were assessed regularly for postoperative seizure control. Outcome after at least 3 years was evaluated using Engel's classification for epilepsy. The chi2 test was used to compare categorical data. RESULTS: Seventy-eight patients were included in this study. Eight patients were excluded because of inadequate follow-up. Thirty-five patients (44.9%) had unilateral isolated hippocampal atrophy exclusively on MRI volumetry, 29 (37.2%) had unilateral hippocampal atrophy with ipsilateral fornix atrophy, and 6 (7.7%) had isolated fornix atrophy without hippocampal atrophy. Twenty-eight patients (80%) in the unilateral hippocampal atrophy group were seizure free (ie, Engel class 1: patients who are completely seizure free with no aura and who do not receive antiepileptic drugs) compared with 21 patients (73%) in the fornix and hippocampal atrophy group (P =.57). All 6 patients with isolated fornix atrophy achieved an Engel's class 1 outcome. CONCLUSIONS: These findings suggest that identification of fornix atrophy with or without associated hippocampal atrophy is not an important preoperative determinant of surgical outcome. However, in the presence of a normal hippocampus, fornix atrophy may be valuable in predicting seizure-free outcome.

Adolescent↗
PubMed1998

Radical Sphincter preservation surgery with coloanal anastomosis following high-dose external irradiation for the very low lying rectal cancer.

High-dose preoperative radiation and specifically designed surgical techniques were used to extend the application of sphincter preservation surgery for cancer of the distal 3 cm of the true rectum. A total of 203 consecutive patients with rectal cancer were treated with external-beam irradiation (45-70 Gy) and radical curative surgery. The cancer was at the level of 0.5-3.0 cm in 65 patients. In these 65 patients treated by radical resection with coloanal anastomosis six suffered recurrence (9%), and the 5-year actuarial survival was 85%. There was a single death. There was no local recurrence among 44 patients in whom the postradiated cancer resided in the rectal wall with or without nodal involvement. With proper selection, high-dose preoperative radiation therapy thus permits extended use of sphincter preservation surgery with coloanal anastomosis for cancers of the distal 3 cm of the true rectum.

Adult↗
PubMed2000

[Laparoscopic cardiomyotomy in the treatment of achalasia].

The laparoscopic cardiomyotomy (Heller) with Dor type anterior fundoplication is accepted for treatment of esophageal achalasia. Between December 1994 and December 1998, 21 patients with esophageal achalasia underwent laparoscopic Heller's operation with Dor's antireflux procedures after preoperative assessment which involved radiological, endoscopic and manometric investigations. Results were evaluated on the basis of our experiences and postoperative investigations. There were no intraoperative complications. Operating time was 40-90' (mean 65'). Conversion to laparotomy was not required. One patient had postoperative stenosis, and another had esophageal perforation which was treated. Postoperative manometry in all patients showed a decreased lower esophageal sphincter pressure. Based on the obtained results it could be concluded that cardiomyotomy with Dor fundoplication through a laparoscopic approach leeds to good functional results and seems effective and safe procedure in the treatment of esophageal achalasia.

Adolescent↗
PubMed2006

Exploratory thoracotomy and its influence on the survival of patients with lung cancer.

PURPOSE: To evaluate diagnostic procedures, reasons for exploratory thoracotomy (ET), causes of unresectability of lung cancer, possibility for reducing numbers of ETs, and the influence of ET on survival. PATIENTS AND METHODS: Between 1990 and 1999, 1808 patients with lung cancer were operated on. ET was performed in 165 (9.1%) of these cases. In total, 131 ET patients were evaluable for analysis. The clinical stages were: three patients in stage IA, 28 in IB, one in IIA, 35 in IIB, 50 in IIIA, 10 in IIIB (all due to invasion of the mediastinum), and four patients in IV (three with ipsilateral pulmonary and one with solitary suprarenal metastasis). The control group for calculating survival difference consisted of 130 consecutive non-operated patients with comparable characteristics (age, sex, clinical stage, performance status, histology and comorbidity) who were diagnosed during the period 1996-1998. RESULTS: The diagnostic procedure before ET comprised bronchoscopy in all patients, transthoracic needle biopsy in 13, cervical mediastinoscopy in nine, parasternal mediastinotomy in two and thoracoscopy in two, in all patients without proving unresectability. A CT scan was performed in 118 patients indicating resectability in 33%, doubtful resectability in 64% and unresectability in 3%. Clinical and surgical staging were equal in 3% of stage IIB patients, in 24% of stage IIIA, 100% of stage IIIB and 75% of patients in stage IV. The 30-day operative mortality was 4.6%. The reasons for ET were: diagnosis of preoperatively unverified tumor in one patient, necessity for pneumonectomy in the case of poor pulmonary function in 11 patients, and unresectability in 119 (due to invasion of the mediastinum in 98 patients, thoracic wall in three and vertebral body in one, and due to pleural metastases in 17 patients). ET could have been avoided in 15 (11%) patients. The median survival for both ET and control group patients was 11.1 months. The survival difference was not statistically significant (p = 0.420). CONCLUSION: ET could be partly avoided through a more accurate preoperative staging procedure. It does not appear possible to avoid ET in patients with limited pulmonary reserve precluding a resection larger than that predicted, nor to avoid ET as a consequence of intraoperative complications. Despite operative mortality, ET did not significantly influence the survival rate in the present study.

Adrenal Gland Neoplasms↗