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PubMed1993

Racial differences in the use of invasive coronary procedures after acute myocardial infarction in Medicare beneficiaries.

We examined differences in the use of invasive diagnostic and therapeutic coronary procedures between white and black Medicare beneficiaries following acute myocardial infarction. We used Medicare hospitalization data for patients aged 65 years or older who were hospitalized with an acute myocardial infarction in 1988, and we followed them through the calendar year to determine whether they received invasive coronary procedures. We used multivariate logistic regression to control simultaneously for multiple potential confounding factors including age, geographic region, poverty, comorbid conditions, access to hospitals equipped to provide invasive procedures, and short-term survival. We calculated odds ratios for racial differences in use of invasive diagnostic procedures (coronary arteriography, cardiac catheterization) and, separately, of myocardial revascularization procedures (coronary artery bypass grafting, percutaneous transluminal coronary angioplasty). We found that the odds of receiving an invasive diagnostic procedure after acute myocardial infarction were 2.0 times greater for white men than for black men (95% CI: 1.8-2.1); for white women, the odds were 1.5 times greater than for black women (95% CI: 1.4-1.6). Following an invasive diagnostic procedure, the odds of myocardial revascularization were 1.8 times greater among white than among black men (95% CI: 1.6-2.0), and 1.7 times greater among white than among black women (95% CI: 1.6-2.0). We conclude that invasive diagnostic and therapeutic coronary procedures are used more often among white than among black Medicare beneficiaries following acute myocardial infarction. Further investigation of this discrepancy will require detailed clinical and attitudinal information from medical records, patients, and physicians.

Black or African American↗
PubMed1994

A hospital review of advanced gynecologic endoscopic procedures.

OBJECTIVE: Our purpose was to review the findings of a Gynecologic Endoscopic Review Committee established to monitor and review operative endoscopic procedures performed by the staff at a large private hospital, Swedish Hospital Medical Center, in Seattle. STUDY DESIGN: Hospital charts of patients undergoing the endoscopic procedures under review are pulled monthly, and the data are extracted, particularly as related to performance of the procedures, length of surgery and hospitalization, and occurrence of complications. This study is a compilation of the committee's review of a 15-month interval, Jan. 1, 1992, to March 31, 1993. RESULTS: Forty-two surgeons performed 227 endoscopic procedures on 218 patients, 100 hysteroscopically and 127 laparoscopically. Significant complication rates were associated with the transhysteroscopic operative procedures and with many of the translaparoscopic procedures, including oophorectomy, ovarian cystectomy, myomectomy, pelviscopic lysis of adhesions, and laparoscopic-assisted vaginal hysterectomy. CONCLUSIONS: A significant complication rate was found for many of the advanced endoscopic procedures performed at Swedish Hospital Medical Center. This is likely related to operator inexperience in performing relatively difficult endoscopic procedures involving new and ever-expanding arrays of techniques and instruments.

Female↗
PubMedDate not supplied

Thrombolytic therapy before reconstructive vascular procedures for acute or subacute graft occlusions.

The purpose of this study was to evaluate the efficacy of direct intra-arterial Urokinase infusions prior to anticipated adjunctive reconstructive vascular procedures in 16 patients with 24 acutely or subacutely occluded lower extremity grafts (22 femoropopliteal, 2 femorotibial). Complete thrombolysis was achieved angiographically in 18 (75%) of 24 graft occlusions. Neither age, gender, current smoking, diabetes mellitus, hypertension, nor coronary arterial disease were significantly associated with complete thrombolysis. The only significant factor related to complete thrombolysis was the duration of the occlusion prior to lytic treatment (p < 0.05). Adjunctive reconstructive procedures were performed for eleven of 18 cases in which complete thrombolysis was achieved. These included nine percutaneous transluminal balloon angioplasties (at eight distal and one proximal anastomotic stenoses) and two bypass operations (femoropopliteal). The remaining seven cases had no adjunctive procedure. These 18 cases were examined for patency rates during nine months of follow-up. Six (54%) of 11 cases with adjunctive reconstructive vascular procedures remained patent, while one (14%) of seven cases with no adjunctive procedure remained patent (p = 0.1). Six (25%) of 24 cases resulted in incomplete thrombolysis. Vascular procedures following these cases included two bypass operations, three amputations and one sympathectomy. This study suggests that complete thrombolysis of acutely occluded grafts might have minimized subsequent reconstructive procedures. Identification of correctable lesions and adjunctive reconstructive procedures performed following complete thrombolysis may be the important factors related to long-term patency.

Angioplasty, Balloon↗
PubMed1997

Total knee arthroplasty infections associated with dental procedures.

Total knee arthroplasties are at risk for hematogenous seeding secondary to procedures that create a transient bacteremia. To define the risk of infection associated with dental surgery, a retrospective review of the records of 3490 patients treated with total knee arthroplasty by the authors between 1982 and 1993 was performed. Sixty-two total knee arthroplasties with late infections (greater than 6 months after their procedure) were identified, and of these, seven infections were associated strongly with a dental procedure temporally and bacteriologically. These seven cases represented 11% of the identified infections or 0.2% of the total knee arthroplasty procedures performed during this period. In addition, among 12 patients referred for infected total knee arthroplasties from outside institutions, two infections were associated with a dental procedure. Five of the nine (56%) patients had systemic risk factors that predisposed them to infection, including diabetes and rheumatoid arthritis. All dental procedures were extensive in nature (average, 115 minutes; range, 75-205 minutes). Eight of the patients received no antibiotic prophylaxis. One patient had only one preoperative dose. Infections associated with dental procedures may be more common than previously suspected. Eight of these patients had no prophylactic antibiotics, and one had inadequate coverage. The authors think that patients with a total knee arthroplasty who have systemic disease that compromises host defense mechanisms against infections and who undergo extensive dental procedures should receive prophylactic antibiotics. A first generation cephalosporin, given 1 hour preoperatively and 8 hours postoperatively would provide the best prophylaxis against the organisms identified in this study.

Aged↗
PubMed1998

Procedures in ambulatory care. Which family physicians do what in southwestern Ontario?

OBJECTIVE: To determine how often family physicians perform 12 ambulatory care procedures and factors associated with procedure performance. DESIGN: Mailed, self-administered survey. The survey was conducted according to the Dillman Total Design method. SETTING: Family physicians' offices in London, Ont, and in surrounding communities. PARTICIPANTS: A total of 395 family physicians practising within the London area were mailed surveys, 237 in London and 158 outside London. Response rates were 80.6% and 75.9%, respectively. Nonresponders did not differ significantly from responders in sex but included more solo practitioners. MAIN OUTCOME MEASURES: Performance of ambulatory care procedures, sex, and practice characteristics of participant family physicians. RESULTS: For all responders, activities significantly associated with procedure performance were delivering babies, managing psychological problems, working emergency, and teaching. Mean total procedure scores ranged from 6.55 for managing psychological problems to 7.68 for working emergency. Sex-specific analysis showed that practice location and years in practice were significant factors for female but not for male family physicians. Mean total procedure scores for female physicians were 7.06 (outside London) and 4.74 (in London). CONCLUSIONS: Factors associated with procedure performance for family physicians in and around London included delivering babies, working in emergency, managing psychological problems, and teaching. Practice location was a significant factor for only female family physicians; those practising outside London performed procedures more than their urban counterparts and at similar rates to male physicians.

Ambulatory Care↗
PubMed1998

Time of removal of femoral sheaths after interventional procedures: comparison of hemoglobin and hematocrit values.

BACKGROUND: Few investigators have examined the time of removal of femoral sheaths after interventional procedures and its effect on patients' hematocrit and hemoglobin levels. OBJECTIVE: To determine if hematocrit and hemoglobin values differed significantly according to the length of time femoral sheaths remained in place after interventional procedures. METHODS: After a review of the literature, data were collected on a convenience sample consisting of 2 groups. Patients in group 1 (n = 30) had femoral sheaths removed within 3.5 to 9.0 hours (mean, 5.5 hours) after an interventional procedure. Patients in group 2 (n = 30) had the sheaths removed within 17 to 36 hours (mean, 22 hours) after an interventional procedure. Blood samples were obtained from all patients before the interventional procedure (baseline values) and again 1 day after the procedure. Patients in group 1 had sheaths removed before the second blood sample was obtained; patients in group 2 did not. Data were analyzed by using an equal-variance t test to determine if hematocrit and hemoglobin values differed significantly between the 2 groups. RESULTS: Hematocrit and hemoglobin values the day after interventional procedure differed significantly in the two groups. CONCLUSION: Earlier removal of femoral sheaths may have a beneficial physiological effect. The results indicate that prompt removal of femoral sheaths after interventional procedures improves patients' outcomes.

Adaptation, Physiological↗
PubMed1998

Adduction arytenopexy: a new procedure for paralytic dysphonia with implications for implant medialization.

Arytenoid adduction was designed to enhance posterior glottal closure in patients with paralytic dysphonia by reproducing lateral cricoarytenoid muscle function. However this procedure can exaggerate normal medial rotation of the vocal process, because the agonist-antagonist function of the interarytenoid, lateral thyroarytenoid, and posterior cricoarytenoid muscles is not simulated. Therefore, a new adduction procedure (adduction arytenopexy) was devised to affix the arytenoid on the cricoid facet in a more optimal position for glottal sound production. The adduction arytenopexy procedure was designed on fresh cadavers. In this technique, the lateral aspect of the cricoarytenoid joint is opened widely and the body of the arytenoid is manually medialized along the cricoid facet. A specially designed single suture is then placed through the posterior cricoid and the body or the muscular process of the arytenoid to achieve 2-point fixation. This draws the arytenoid posteriorly, superiorly, and medially for precise positioning. The arytenoid is rocked internally on the cricoid facet, and suture tension is adjusted appropriately to simulate normal cricoarytenoid adduction. In the first study, the adduction arytenopexy was compared with the classic arytenoid adduction in 10 fresh cadaver larynges. The new arytenopexy procedure resulted in an average increase of 2.1 mm (p < .01) in the length of the musculomembranous vocal fold, whereas the classic arytenoid adduction did not reveal a significant change in length. Additionally, the adduction arytenopexy resulted in a consistently higher vocal fold and a more normally contoured arytenoid than the classic adduction procedure. The second study consisted of a clinical trial in which 12 patients, who presented with a widely patent posterior glottis, underwent adduction arytenopexy in conjunction with implant medialization. The procedure was successful in all patients, and there were minimal complications. In the third study, preoperative and postoperative vocal assessment measures (stroboscopic, aerodynamic, acoustic, and perceptual) were analyzed in 9 of the 12 patients. The most striking preoperative stroboscopic observation was that 8 of the 9 patients presented with an aperiodic vibrational flutter during phonation due to severe valvular incompetence. Postoperatively, all patients developed complete closure of the glottal chink and effective entrained oscillation of the vocal folds. This visual improvement in function was commensurate with comparable changes in most of the other objective and subjective measures of vocal function. The new adduction arytenopexy procedure closely simulates the biomechanics underlying normal glottal closure and cricoarytenoid adduction. In turn, complex implant design shapes are not necessary to achieve proper alignment of the arytenoid and the vocal fold. Because the arytenoid is properly positioned prior to the medialization, implants can be sized more precisely and are unencumbered by an anterior thyroid lamina suture. These procedural innovations resulted in enhanced entrained oscillation of the glottal valve and, in turn, improved laryngeal sound production.

Cadaver↗
PubMed1998

[Complications of plateletpheresis procedures].

PURPOSE: Thrombopheresis procedures have been recently expanded with the development or different programmes. Taking into account that this reasonably safe procedure is not devoid of complications, it would be desirable to select those individuals with lower risk of suffering adverse side effects as donors. The thrombopheresis procedures performed in our hospital between 1986 and 1997 were analysed in order to establish the useful guidelines for such selection. MATERIAL AND METHODS: All the thrombopheresis procedures performed in the Asturias Central Hospital blood bank in the 1986-1987 period were analysed. The first procedure per donor, along with all data referred to adverse effects appearing during thrombopheresis, were collected. Sex, age, body, weight, blood cells count (before and after thrombopheresis) and serum calcium levels (before and after thrombopheresis) were taken as variables with predictive value for adverse effects. With regard to the procedure, the model of cell separator, the duration of the procedure, the amount and type of anticoagulant solution and the prophylactic use of calcium ions were assessed. RESULTS: A total number of 1,024 thrombophereses were analysed. Some types of adverse effect were seen in 259 instances (25.3%). Of these, 70.3%, were mild, 29.3% moderate and 0.4% severe. The commonest adverse effect was perioral paraesthesia. Of the different variables studied, female sex and low weight acquired predictive value with respect to the occurrence of adverse effects. Prophylactic administration of calcium did not prevent the appearance of complications. CONCLUSIONS: The thrombopheresis procedures may present adverse side effects in a high percentage of cases, which, although mostly mild, require specialised personnel for identification and management. Males weighing over 70 kg are less prone to suffer such effects. Oral administration of calcium before the apheresis does not prevent the adverse reactions.

Adult↗
PubMed2005

Endoscopic antireflux therapy: the Stretta procedure.

The Stretta procedure is safe and effective for the treatment of GERD. There are well-documented clinical trial data supporting its use, including a randomized sham-controlled study, single- and multi-center prospective trials, and community practice reports. The complication rate is within the acceptable range for therapeutic endoscopic procedures and less than the published complication rate for laparoscopic fundoplication. The durability of effect also is established beyond 2 years in several studies. Stretta should be added to the GERD management algorithm specifically for patients considering an antireflux surgical procedure but who are not accepting of the risks of surgery and anesthesia. These patients typically present with incomplete GERD control, despite optimal antisecretory drug therapy, or intolerance to medical therapy. Stretta should be considered only for patients who fit the anatomic inclusion criteria, whereas antireflux surgery should be reserved for those who do not. The decision to undergo antireflux surgery or Stretta must be based on the relative risks and benefits of each procedure. Although antireflux surgery provides better control of esophageal acid exposure than Stretta, the outcomes for GERD symptoms, quality of life, and reduction in PPI use are comparable. Stretta has a low risk of acute adverse events, has no reported cases of long-term dysphagia, and obviates general anesthesia and hospitalization, whereas antireflux surgery has a reported adverse event rate of approximately 2%, a considerable incidence of dysphagia, and requires general anesthesia and 1 to 2 days in the hospital. Another advantage of the Stretta procedure is that antireflux surgery still can be performed in the case of failures. In conclusion, the Stretta procedure offers a minimally invasive, safe, and effective alternative to antireflux surgery for those patients who have GERD who are controlled unsatisfactorily on antisecretory medications, who are considering surgery, and who meet the anatomic criteria that make the procedure technically feasible and safe.

Ambulatory Surgical Procedures↗
PubMed2001

Can a single individualized procedure predictably resolve all the problematic aspects of the pediatric ureterocele?

PURPOSE: During the last 10 years we attempted to treat most children presenting with a ureterocele with a single definitive operative procedure. We reviewed the surgical results to assess the success of the preoperative plan in achieving this outcome. MATERIALS AND METHODS: We retrospectively reviewed the records and diagnostic studies of all children who underwent surgery for a ureterocele during the last 10 years at our institution. The intent of the surgeon as to whether the procedure was intended to be definitive was stated in the clinic notes in all cases. RESULTS: Surgery for a ureterocele was performed in 38 children during the study period. Transurethral incision was used in 7 patients and, although it was intended to be definitive in 2, all 7 required subsequent surgery for vesicoureteral reflux. Isolated upper tract surgery was performed with intent to cure in 20 of 21 patients including upper pole heminephrectomy in 17 and upper to lower ureteroureterostomy in 3. Of the 20 patients initially treated with this simplified approach 17 (85%) did not require subsequent surgery for ureterocele and 12 had vesicoureteral reflux preoperatively, which persisted in 2 (10%) and required subsequent surgery in 3 (15%). Total reconstruction of the ureterocele was performed in 10 patients and 1 of whom required subsequent surgery. We achieved resolution of all problematic aspects of the ureterocele with a single procedure in 26 of 32 patients (81%). CONCLUSIONS: A single procedure that definitively treats all problems of a ureterocele can be selected in more than three-quarters of patients. Transurethral incision was unsuccessful at definitively treating these patients in our experience. An isolated upper tract procedure was successful in patients with no or mild associated vesicoureteral reflux. We think that upper tract surgery should be the procedure of choice in this subset of patients, as it usually resolves the problem and does not subject the patient to the potential morbidities of bladder surgery. Although total reconstruction is a more formidable procedure, it can be performed safely with excellent results.

Child↗
PubMed1994

Laparoscopic surgical procedures.

Therapeutic laparoscopic surgical procedures have rapidly become well established. Two commonly stated advantages are decreased postoperative pain and shortened hospitalization and recovery times in comparison with an open surgical procedure. Currently, laparoscopic cholecystectomy is the procedure of choice for most patients with symptomatic gallstones, and many stones in the common bile duct can be retrieved by laparoscopic techniques. Laparoscopic appendectomy is a reasonable alternative with improved diagnostic capabilities in comparison with open appendectomy. Laparoscopic antireflux procedures, bowel resections, and repair of inguinal hernias are being performed in ever-increasing numbers; however, long-term results for these procedures are needed and are unavailable at the present time. Various diagnostic and palliative procedures can be done with use of laparoscopic techniques; they provide effective management with minimal perioperative morbidity. Solid organ resections can be safely undertaken laparoscopically in selected patients in whom the target organ is not massively enlarged. Currently, the indications for laparoscopic operations continue to broaden; however, long-term evaluation of laparoscopic surgical results and further improvements in technique and instrumentation are necessary before the appropriate and complete spectrum of laparoscopic surgical procedures will be realized.

Biliary Tract Surgical Procedures↗
PubMed2003

Propofol sedation by emergency physicians for elective pediatric outpatient procedures.

STUDY OBJECTIVE: We describe the efficacy of propofol sedation administered by pediatric emergency physicians to facilitate painful outpatient procedures. METHODS: By using a protocol for patients receiving propofol sedation in an emergency department-affiliated short-stay unit, a prospective, consecutive case series was performed from January to September 2000. Patients were prescheduled, underwent a medical evaluation, and met fasting requirements. A sedation team was present throughout the procedure. All patients received supplemental oxygen. Sedation depth and vital signs were monitored while propofol was manually titrated to the desired level of sedation. RESULTS: There were 291 separate sedation events in 87 patients. No patient had more than 1 sedation event per day. Median patient age was 6 years; 57% were male patients and 72% were oncology patients. Many children required more than 1 procedure per encounter. Most commonly performed procedures included lumbar puncture (43%), intrathecal chemotherapy administration (31%), bone marrow aspiration (19%), and bone biopsy (3%). Median total propofol dose was 3.5 mg/kg. Median systolic and diastolic blood pressures were lowered 22 mm Hg (range 0 to 65 mm Hg) and 21 mm Hg (range 0 to 62 mm Hg), respectively. Partial airway obstruction requiring brief jaw-thrust maneuver was noted for 4% of patient sedations, whereas transient apnea requiring bag-valve-mask ventilation occurred in 1% of patient sedations. All procedures were successfully completed. Median procedure duration was 13 minutes, median sedation duration was 22 minutes, and median total time in the short stay unit was 40 minutes. CONCLUSION: Propofol sedation administered by emergency physicians safely facilitated short painful procedures in children under conditions studied, with rapid recovery.

Adjuvants, Anesthesia↗
PubMed1997

Incidence and outcome of major non-pulmonary surgical procedures in lung transplant recipients.

OBJECTIVE: Pulmonary transplant recipients are at high risk from various conditions requiring surgical intervention. As little is known about their exact incidence and course, we examined such procedures in detail. METHODS AND PATIENTS: We have retrospectively analyzed major nonpulmonary surgical procedures performed in 124 consecutive patients who received an isolated lung transplant at the University of Vienna between 1989 and December 1995. Twenty-two patients underwent a total of 28 major interventions (22/124 = 17.7%), resulting in an incidence of one procedure every 5.8 patient years of follow-up. The mean interval between transplantation and intervention was 17.9 months (range 3 days to 62 months) with six interventions being carried out during the first month after transplantation. Fourteen emergency operations were performed, the remaining 14 procedures were carried out electively. Overall, 15 abdominal procedures, four thoracic, four orthopedic, two gynecological, one neurosurgical, one urological and one plastic surgery were performed. RESULTS: There was no intraoperative death. Perioperatively, five surgery related deaths were observed (5/28, related mortality 17.9%) with multiple organ failure as the cause of death in all cases. All of these deaths followed emergency operations (5/14 = 35.7%) and all were observed in patients with septic abdominal complications. In contrast, even very extensive procedures were performed electively without related mortality (0/14, P = 0.02). During the first month after transplantation, major surgery was associated with a 50% (3/6) mortality, for late interventions mortality was 9.1% (2/22; P = 0.047). CONCLUSIONS: Pulmonary transplant recipients showed a high incidence of conditions requiring surgical intervention. As expected, septic complications, especially during the immediate post transplant period, carried a very poor prognosis. However, it was reassuring to observe that even extensive surgical procedures could be performed safely without associated mortality in the elective setting.

Adolescent↗
PubMed2000

Similarities and differences in the exercise performance of patients after a modified Fontan procedure compared to patients with complete transposition following a Senning operation.

OBJECTIVE: To investigate cardiopulmonary performance in patients after a Fontan procedure, comparing it to patients following a Senning operation. METHODS: We studied 21 children, with a mean age of 11.1 years, after a total cavopulmonary anastomosis, comparing them to 13 with complete transposition after a Senning procedure, having a mean age of 11.8 years, and 21 control subjects with a mean age of 11.2 years. All were tested on a bicycle ergospirometer. RESULTS: Peak consumption of oxygen, maximal work rate, peak oxygen pulse and endexpiratory pressure of carbon dioxide at a work rate of 1.5 Watt/kg were lowest in patients with a modified Fontan procedure, and highest in the control group (p < or = 0.0278). Production of carbon dioxide, and minute ventilation at a work rate of 1.5 Watt/kg, was highest in the patients after Fontan procedure, and lowest in the healthy subjects (p < or = 0.0163). Production of carbon dioxide per single breath was lower in those having a Fontan procedure (28.9 ml) than in the two other groups (35.1 ml; p = 0.0243). The tidal volume showed no significant differences between the three groups. CONCLUSIONS: The reaction to exercise was identical qualitatively in both groups of patients, and comparable to the behaviour of patients with chronic heart failure. Quantitatively, the results of the patients following a Senning procedure lay between those of control subjects and those who had undergone a Fontan operation. The only exception was dead space ventilation, where the patients after a Fontan procedure differed from the two other groups because of their increased ventilation-perfusion mismatch.

Anastomosis, Surgical↗
PubMed2002

Balloon ablation: is this an outpatient procedure?

Menorrhagia is associated with considerable health consequences. First-line therapy is medical, but when this proves unsuccessful a surgical procedure is often undertaken. It is estimated that as many as one in five women will have a hysterectomy before the age of 60 years. While a curative procedure this is a major operation with both morbidity and mortality associated with it. More conservative procedures have therefore been sought. Balloon therapy was developed in 1994 and it was introduced to Royal Bolton Hospital in 1998. Initially offered under general anaesthesia, an overall a success rate of 91% was achieved in this study, with amenorrhea in 18% of cases. Dysmenorrhea was improved in 60% of patients. Twenty-eight patients received outpatient therapy, under a paracervical block. All patients were given voltarol pretreatment. Subjectively the procedure was well tolerated by most, and objectively 89% of patients rated the procedure as acceptable. Sixty-one per cent of patients would be happy to undertake the procedure again under local anaesthesia. Findings from this study would indicate that balloon ablation does provide an effective, less invasive, alternative treatment for menorrhagia. Despite limited numbers, it would also seem appropriate, in selected patients, to offer this therapy as an outpatient procedure.

Adult↗
PubMed2004

[Minilaparotomy as an access route to vascular reconstruction procedures in the aortoiliac region].

Following the example of general surgical procedures, also vascular surgery gradually minimizes the size of its surgical entrances. Miniinvasive surgical procedures significantly reduce postoperative complaints and shorten the patients recovery rates. Minilaparotomy, either a hand-assisted or a laparoscopy-assisted procedure, a procedure conducted fully via laparoscopy or thoracoscopy and a robot-assisted procedure, all of the above are contemporary options for miniinvasive procedures in the vascular surgery. The authors introduce their initial experience with the use of minilaparotomy in the aortoiliac region. From November 2002 to April 2004, 29 procedures were performed for the abdominal aortic aneurysm repair or for aortoiliac occlusive disease. In 15 cases the abdominal aortic aneurysm was managed and in 14 cases the aortoiliac occlusive disease was managed.

Aged↗
PubMed2006

A new modification of transanal Soave pull-through procedure for Hirschsprung's disease.

BACKGROUND: One stage transanal Soave pull-through procedure (TSPP) is a recent popular operation in the treatment of Hirschsprung's disease (HD). With no visible scar and a short hospital stay, it is well accepted by surgeons and mothers. In the conventional Soave procedure, a long rectal muscular cuff left for anocolic anastomosis might increase the incidence of postoperative enterocolitis and constipation. This study presents a modified transanal Soave pull-through procedure (MTSPP) which includes an oblique mucosectomy and an oblique anastomosis with a short split muscular cuff. METHODS: A review of two groups of HD patients was made: 112 underwent conventional transanal Soave procedure from 1999 to 2001 (group 1) and 140 underwent modified transanal Soave procedure from 2002 to 2004 (group 2). A comparison was made between the two groups on operative data and postoperative complications. The data included: age at the operation, operating time, blood loss, time to feeds and hospital stay, occurrence of postoperative enterocolitis or constipation, need for anal dilatation, postoperative bowel function and perianal skin problems. RESULTS: There was no significant difference between two groups with respect to age, gender, length of colon resected, operating time, blood loss and hospital stay. However occurrence of postoperative enterocolitis, constipation, anastomotic stricture and time needed for anal dilatation were evidently less in group 2 (MTSPP). The mean operating time in group 1 was (106 +/- 39) minutes with a range of 60 to 170 minutes; in group 2 was (101 +/- 36) minutes with a range of 66 to 190 minutes. The average length of the bowel resected in group 1 was (24 +/- 7) cm, range 15 to 58 cm; in group 2 was (26 +/- 8) cm, range 15 to 70 cm. Two patients, one in each group, required laparoscopic assistance because of long aganglionic colon. Another patient in group 2 required laparotomy because of total colonic aganglionosis. Postoperative complications in group 1 included: temporary perianal excoriation in 34 patients (26 were < 3 months of age), enterocolitis in 21, anastomotic stricture in 11, recurrent constipation in 12, cuff abscess in 1, anastomosis leak in 1, soiling in 3 and rectal prolapse in 1. In group 2 post operative complications included: transient perianal excoriation in 37 patients (30 were < 3 months of age), enterocolitis in 13, anastomotic stricture in 5, recurrent constipation in 6, anastomotic leak in 1, adhesive bowel obstruction in 1 and soiling in 4. Complete bowel continence was found in 97 children (86.6%) in group 1 and in 129 children (92.1%) in group 2 at one year followup after operation. CONCLUSIONS: Modified transanal Soave pull-through procedure for HD with oblique mucosectomy and anastomosis and a short split muscular cuff is a safe and feasible operation with low incidence of postoperative complication. It is an encouraging improvement of the conventional transanal Soave pull-through procedure. MTSPP is a preferable choice in the surgery of HD.

Adolescent↗
PubMed2003

Efficacy of the 2-staged procedure in the management of cholesteatoma.

OBJECTIVE: To demonstrate the efficacy of intact canal wall procedure coupled with a second-stage exploration for the treatment of cholesteatoma. DESIGN: Retrospective case study of patients with cholesteatomas treated with staged surgical extirpation. A minimum of 6 months' postoperative follow-up time was required for inclusion into the study. SETTING: Tertiary academic referral center. Patients A total of 35 adult and pediatric patients, ranging from 9 to 65 years of age, who underwent 2-stage procedures for removal of cholesteatomas. INTERVENTIONS: Two-stage procedures, separated by 6 months, performed with posterior tympanotomy approaches. MAIN OUTCOME MEASURES: The presence or absence of cholesteatoma on second-stage look and the subsequent surgical treatment for recurrent cholesteatoma. The overall hearing results after the completion of the 2-staged procedure were calculated. RESULTS: Disease was controlled in 26 (74%) of the patients. Residual and/or recurrent cholesteatomas were found in 9 (26%) of the patients during the second-stage operation. Of these patients, 5 (14% of the total group) ultimately required conversion to canal-wall-down procedure. Average hearing gain at the completion of the second-stage procedure was 9 dB. CONCLUSIONS: A planned 2-stage procedure that uses the posterior tympanotomy approach for the control of cholesteatoma is an effective technique. This approach offers significant potential for hearing preservation and restoration.

Adolescent↗