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PubMed1980

Neonatal surgery.

The scope and the problems of neonatal surgery are illustrated by reviewing a series of 1831 patients operated on over 15 years in one surgical unit. The patients were listed according the surgical subspeciality to which they belong (Tables 1--9). The results show that operative mortality is negligible in the good risk neonates (tumours, urology, orthopaedic and general surgery) but remains significant in the groups of serious malformations with high incidence of prematurity and associated anomalies. The present hospital mortality for patients with anorectal anomalies is about 5%, for spina bifida cystica about 10% and has even in oesophageal and duodenal atresia patients dropped to 15%. For other bowel atresias it is still 25% for gastroschisis and omphalocoele around 35% and for diaphragmatic hernia 50%. Cardiac surgery, including perfusion operations, has become an integral part of neonatal surgery, its present mortality being around 35%.

Congenital Abnormalities↗
PubMed2002

Artificial neural network analysis for predicting pathological stage of clinically localized prostate cancer in the Japanese population.

BACKGROUND: Although prostate cancer has been prevalent in Japan, there has been no particular model for predicting the pathological stage in the Japanese population. We examined whether artificial neural network analysis (ANNA), which is a relatively new diagnostic tool in prostate cancer, can be one of the predictive methods for predicting organ confinement, compared with the traditional logistic regression model, in the Japanese population for the first time. METHODS: The study population comprised 178 men who underwent radical prostatectomy at our institutions between October 1992 and May 1999. As additional pretreatment parameters to the preoperative serum PSA level, clinical TNM classification and biopsy Gleason score, the percentage of number of cores exhibiting traces of tumor, maximum tumor length in biopsy cores, PSA density and patient age were used. The predictive ability of ANNA with several parameters for a set of 36 randomly selected test data was compared with those of logistic regression analysis and 'Partin Tables' by area under the receiver operating characteristics (ROC) curve analysis. RESULTS: Of 178 patients, 97 (54.5%) had organ-confined disease but 81 (45.5%) had locally advanced disease. With three parameters, the area under the ROC curve of ANNA (0.825 +/- 0.071) was larger than those for logistic regression (0.782 +/- 0.079) and Partin Tables (0.756 +/- 0.087), but not to a significant extent (P = 0.690 and 0.541). Although the expansion of the parameters did not increase the difference in area under the ROC curve between the best ANNA and logistic regression (0.899 +/- 0.053 and 0.873 +/- 0.065, respectively), the difference between the best ANNA and Partin Tables did not reach but approached statistical significance (P = 0.157). CONCLUSION: Although more modeling optimization is necessary to improve the predictive accuracy and generalizability of ANNA, we suggest that there is the possibility for this new predictive method to evolve in the analysis of clinical staging of prostate cancer.

Aged↗
PubMed2001

Results of endovascular superficial femoral endarterectomy.

BACKGROUND: Endovascular superficial femoral artery (SFA) endarterectomy with a ring stripper/cutter and distal stenting has been suggested to have a patency comparable with above-knee bypass surgery. We report our initial experience with this technique. METHODS: Seventeen patients (13 men and 4 women; mean age, 64 years) with SFA occlusion and above-knee popliteal reconstitution underwent attempted remote endarterectomy with a ring cutter system combined with primary stenting of the distal end point. Analysis was performed in a prospective manner with patency rates determined by Kaplan-Meier life-table analysis. RESULTS: The indication for operation was claudication in 8 patients, rest pain in 6, and tissue loss in 3. Initial technical success was achieved in 11 patients (65%). Reasons for technical failure included SFA perforation (4), inability to traverse a calcified/diseased segment (1), and inability to retract/remove the ring cutter (1). Life-table analysis of all patients revealed a primary patency at 1 year of 26% +/- 11%. Primary-assisted patency was 38% +/- 12% at 1 year, with 59% of patients ultimately requiring surgical bypass grafting. In patients in whom initial technical success was achieved, the 1-year primary and primary-assisted patency rates were 40% and 59%, respectively. There were four reocclusions requiring surgical revascularization with below-knee popliteal (2) or tibial (2) bypass grafting, 1 symptomatic restenosis requiring repeat angioplasty, and 1 symptomatic restenosis treated conservatively. CONCLUSION: The results of endovascular SFA endarterectomy were disappointing, with technical success in less than two thirds of patients and a 1-year primary patency of only 26%. Remote SFA endarterectomy appears less effective than above-knee femoropopliteal bypass grafting, and after early failure, patients may require more distal revascularization for limb salvage.

Angioplasty↗
PubMed2006

Improving the accuracy of BRCA1/2 mutation prediction: validation of the novel country-customized IC software.

Inherited mutations of the BRCA1/2 genes confer a significantly increased risk for breast and/or ovarian cancer development. Several models were elaborated to help genetic counsellors in selecting individuals with high probability of being mutation carriers. The IC software, a country-customized version of the Brcapro model, was recently shown to be particularly accurate in the prediction of carrier probability status in the Italian population. Here, we used our independent series of 70 breast/ovarian cancer families to analyze the performances of the IC software and compare it to widely used models, such as Brcapro and the Myriad mutation prevalence tables. Analysis of the areas under the receiver operator characteristics (ROC) curves indicated that overall the models performed well. However, the IC software and Myriad tables were more efficient in predicting mutated cases, showing a higher sensitivity (94 and 88%, respectively) and negative predictive value (NPV, 94 and 92%, respectively) compared to Brcapro (sensitivity 71 and NPV 83%). IC software also appeared particularly accurate in the identification of families belonging the low mutation risk group (<10%). Finally, most Brcapro failures occurred in the hereditary breast cancer (HBC) family subset, and in 75% of the cases, the IC software corrected them. Our data suggest that the country-customized implementation operated on the Brcapro software generated a more accurate tool for the prediction of BRCA1/2 gene mutation. Whether the IC or other country-customized models might improve BRCA1/2 mutation prediction also in non-Italian families needs to be further explored.

BRCA1 Protein↗
PubMedDate not supplied

[Postoperative changes in diastolic function of the left ventricle in patients with aortic valve stenosis].

INTRODUCTION: Diastolic dysfunction in valvular aortic stenosis frequently precedes systolic dysfunction. The purpose of this study was to examine the changes in left ventricular diastolic function after aortic valve replacement. METHODS: Seventy eight patients with significant isolated valvular aortic stenosis were enrolled in the study. The echocardiographic examination was performed with ACUSON-XP 10 imaging system. Complete M-mode, 2-dimensional and Doppler echocardiographic results were obtained. In 48 patients right and left heart catheterisation was performed. Left ventricular diastolic function was evaluated by pulse Doppler recording of inflow velocity on the tips of the mitral valve leaflets. Forty two underwent aortic valve replacement. They were followed up 6-12 months postoperatively. RESULTS: Abnormal patterns of left ventricular diastolic filling were noticed in almost all patients (Table 1). Most prominent changes were found in subjects with marked and diffuse hypertrophy (Table 2). After aortic valve replacement decrease in left ventricular size, mass, pressures and improvement in systolic Function (Table 3). Twelve months after the operation late diastolic filling velocity was lower (A = 64 +/- 15 cm/s, Avti = 7.1 +/- 1.8 cm), early diastolic filling velocity was higher (E = 83 +/- 14 cm/s, Evti = 10.3 +/- 1.4 cm), deceleration time (DT = 123 +/- 14 ms) and isovolumetric relaxation time (IRT = 66 +/- 6 ms) were longer in patients with preoperative moderate hypertrophy (Table 4). In patients with severe left ventricular hypertrophy changes in diastolic function were slower. We found decrease in early diastolic filling velocity (A = 44 +/- 6 cm/s, Avti = 4.6 +/- 04 cm), increase in late diastolic filling velocity (E = 67 +/- 14 cm/s, Evti = 9.4 +/- 1.7 cm), with prolongation of deceleration (DT = 131 +/- 18 ms) and isovolumetric relaxation time (IRT = 94 +/- 23 ms) (Table 5). DISCUSSION: In adults with significant sympthomatic aortic valve stenosis, aortic valve replacement is therapy of choice. Replacement of the diseased aortic valve with a prosthetic valve yields relief of left ventricular outflow obstruction. Myocardial remodeling with regression of mass transpires as the heart adapts to the new level of afterload. In patients with moderate left ventricular hypertrophy improvement in diastolic function during the first year after aortic valve replacement is visible, while in patients with extreme myocardial hypertrophic changes it was slower.

Adolescent↗
PubMed2004

Preoperative neural network using combined magnetic resonance imaging variables, prostate specific antigen and Gleason score to predict prostate cancer stage.

PURPOSE: We developed an artificial neural network analysis (ANNA) to predict prostate cancer pathological stage more effectively than logistic regression (LR) based on the combined use of prostate specific antigen (PSA), biopsy Gleason score and pelvic coil magnetic resonance imaging (pMRI) in patients with clinically organ confined disease before radical prostatectomy. MATERIALS AND METHODS: In 201 consecutive patients undergoing radical retropubic prostatectomy with pelvic lymphadenectomy the radiological-pathological correlation was evaluated using pMRI. Predictive variables were clinical TNM classification, preoperative serum PSA, biopsy Gleason score and pMRI findings. The predicted results were organ confined vs nonorgan confined disease and lymphatic vs no lymphatic involvement. The predicted ability of ANNA with several parameters in a set of 160 randomly selected test data was compared with that of LR and the Partin tables by area under the receiver operating characteristic curve analysis. RESULTS: The overall accuracy of ANNA and LR was 88% and 91%, and 77% and 84% for nonorgan confined and lymphatic involvement, respectively. For nonorgan confined disease and lymph node involvement the area under the curve of ANNA (0.895 and 0.899) was significantly larger than that of LR and the Partin tables (0.722 and 0.751, and 0.750 and 0.733, respectively, p <0.05). Gleason score represented the most influential predictor (relative weight 2.05) of nonorgan confined disease, followed by pMRI findings (1.96), PSA (1.73) and clinical stage (0.89). CONCLUSIONS: ANNA is superior to LR for accurately predicting pathological stage. The relative importance of pMRI findings and the usefulness of ANNA for predicting pathological stage in individuals must be confirmed in a prospective trial.

Adult↗
PubMed1994

[Surgical treatment for postinfarction ventricular septal perforation].

Between August 1981 and August 1992, operation for ventricular septal perforation (VSP) after acute myocardial infarction (AMI) was performed in 12 patients and the results were studied. During this period, medical treatment was attempted as a standard therapy for more than two weeks after AMI, followed by operation. However, only four patients received elective operation two weeks after the onset of AMI. Regarding the relationship between the preoperative circulatory status and timing of surgery, elective operative could not be performed in seven patients showing a pulmonary to systemic flow ratio (Qp/Qs) of more than 3.0, while four out of five patients with a ratio of less than 3.0 received operation more than two weeks after the onset of AMI. Two patients with severe right heart failure after the repair of VSP died on table without weaning from the pump. Ten operative survivors were weaned from the pump without any difficulty of hemostasis and intraaortic balloon pumping was removed after operation. However, three patients died of multiple organ failure which had been deteriorating before operation. Postoperative activity improved to New York Heart Association Functional Class I or II in six survivors for the late follow-up period. In the case of high Qp/Qs due to VSP, early operation is recommended to prevent multiple organ failure.

Aged↗
PubMed1992

Radioexposure levels observed with sub-optimal fluoroscopic systems.

Contemporary radiology increasingly performs invasive procedures for therapeutic purposes. These new requirements stress the patient's and the workers' (physicians, nurses and technologists) radiological exposure, specifically during long periods of fluoroscopy. The worker-exposure level and the patient's dose are related to the equipment geometry (i.e., an above- or under-table-top x-ray tube), the medical practice, the operating mode and the overall performance of the equipment. Using the effective dose concept for the patient and the exposure rate at the operator body surface for some spatial locations around the equipment, the authors show the variation on the dose to the patient and the operator while a collimator is opened larger than the detector size. They stress that a non-optimum opening size of the collimator may be penalizing for the patient and for the operator, specifically when the latter works near equipment mounted with an over-table-top x-ray tube. This particular piece of an equipment is the easiest one to control and maintain. Better use and better quality control should contribute to significantly reducing patient and operator exposure. The authors present statistics obtained on equipment surveyed in 1990 to comply with the Quebec Public Protection Law.

Film Dosimetry↗
PubMed1975

Anaesthesia for posterior cervical osteotomy.

We have studied 22 consecutive cases of posterior cervical osteotomy done at the Toronto East General Hospital between October 1967 and November 1973. The anaesthetic management is discussed in some detail and consists of psychological preparation of the patient, and neuroleptanalgesia with infiltration with local anaesthetic by the surgeon. The reasons for this choice of technique have been discussed in some detail. There were no deaths during operation, but one patient suffered collapse on the table, which was thought to be due to air embolism. One patient died three weeks post-operatively of pulmonary embolism. Experience in anaesthetizing patients who require operation after previous posterior cervical osteotomy is mentioned briefly and techniques are recommended for successful management of such cases.

Adult↗
PubMed2000

[The age-specific results of the adjuvant radiotherapy of breast carcinoma].

BACKGROUND: Aim of our work was to evaluate the standards of treatment in elder women with breast cancer and their results of radiation therapy. PATIENTS AND METHODS: In our hospital 218 breast cancer patients were treated in the years 1990 and 1991. Forty-three women were younger than 50 years of age (group I), 92 between 50 and 64 years (group II), 83 elder than 64 years (group III). One hundred and forty-nine patients underwent mastectomy, 65 patients had conservative treatment (Table 5). Four patients were not operable. All of the patients were irradiated uniformly loco-regionally with 50 Gy Co-60-photons, followed by a boost to the tumor bed with 10 Gy with 6- to 12-MeV electrons. Forty-four patients had an additional chemotherapy. RESULTS: The 5-year survival rate was 79.8% (n = 174), the disease free survival was 59.1% (n = 129) (Table 6). The mean rate of local recurrence was 3.6% (n = 8), 4% after mastectomy (n = 6) and 3% (n = 2) with breast conservation. Age group specific 5-year survival rates were 72% (I), 85.6% (II) and 77.1% (III), respectively, disease free survival rates were 48.8% (I), 65.2% (II) and 57.8% (III), respectively. The rates of local recurrence were 9.3% (I), 3.2% (II) and 1.2% (III), respectively. Significant age group specific differences in surgical and radiotherapeutical treatment could not be found. CONCLUSION: The curative chance of treatment has to be used in every age. A treatment of elder patients below the actual valid standards of treatment is not justified.

Adult↗
PubMed1996

Laparoscopic hernia repair--what are the results?

The two widely practised laparoscopic groin hernia repairs are: a) trans-abdominal preperitoneal (TAPP) and b) trans-extraperitoneal preperitoneal (TEPP) approaches. Early results are encouraging with both the techniques being associated with low recurrence rates (0% to 2%) comparable to the best, reported for standard open repair (Shouldice and Lichtenstein's). Other complications are higher in the beginning following laparoscopic hernia repair compared to the conventional method. These complications are related to the learning curve and expected to come down significantly with increasing experience of surgeons. Laparoscopic repair of recurrent groin hernia appears to be considerably superior to the conventional technique. The recurrence rates following conventional repair of recurrent groin hernias are between 1.5% and 35% (Table I) compared to none for laparoscopic repair of recurrent inguinal hernias. The disadvantages of laparoscopic repair include greater technical difficulty, higher incidence of serious complications and increased cost. Sutured open repair is associated with high postoperative discomfort, greater difficulty of repairing recurrent hernia with higher societal cost (due to prolonged time-off from work for 12% to 57% of patients operated for various open technique-Table II). The techniques of laparoscopic hernia repairs are nearly standardised today. Laparoscopic surgeons have an obligation to offer the new alternative and to ensure that it is safely used. Laparoscopic repair is another technique used for the repair of inguinal hernias, which is going to stay as a safe and effective alternative to open repair as the learning curve is over. There is an urgent need to have well-designed prospective randomised trials in the near future.

Hernia, Inguinal↗
PubMedDate not supplied

Analysis of radiation scatter during angiographic procedures: evaluation of a phantom model and a modified radiation protection system.

PURPOSE: To study the radiation scattering associated with the digital subtraction angiography (DSA) unit in angiographic procedures and to design an effective radiation protection shield based on these data. MATERIALS AND METHODS: The number of scattered photons was measured at three points relative to the operator's position. Anteroposterior abdominal and lateral cranial fluoroscopy were evaluated. As protective devices, a lead curtain, sliding shields, and a brim-shaped image intensifier (II) hood were designed. RESULTS: In abdominal fluoroscopy, radiation was found to scatter to the operator's lower limbs from the underside of the catheter table, to the abdomen from the side of the patient's body, and to the head and neck from the table surface adjacent to the patient. The use of protective devices reduced exposure from 2.89 to 0.058 mR/min for the operator's lower limbs, from 0.987 to 0.069 mR/min for the operator's abdomen, and from 0.696 to 0.139 mR/ min for the operator's head and neck area. With lateral cranial fluoroscopy, radiation was detected to scatter to the operator's lower limbs from the underside of the catheter table, to the abdomen from the patient's temporal area, and to the head and neck from the patient's face. The use of protective devices reduced exposure from 0.248 to 0.010 mR/min for the operator's lower limbs, from 0.129 to 0.010 mR/min for the operator's abdomen, and from 0.162 to 0.018 mR/min for the operator's head and neck area. CONCLUSIONS: The characteristic directions of scattering to the operator were identified. An effective modified radiation protection system was designed based on this information.

Abdomen↗
PubMed1994

Doppler evaluation of renal artery stenosis: interobserver agreement in the interpretation of waveform morphology.

OBJECTIVE: Analysis of Doppler waveform morphology for features of the tardus-parvus phenomenon has been promoted as a useful and accurate means for detecting renal artery stenosis. The purpose of this study was to examine and quantify the interobserver agreement of such an analysis and to determine if interobserver differences limit the value of this approach for predicting renal artery stenosis. SUBJECTS AND METHODS: Four observers independently categorized renal artery waveforms of 47 patients (94 kidneys) clinically selected for renovascular hypertension. Waveforms were classified into five categories based on the presence and severity of tardus-parvus changes in the systolic upstroke and early systolic peak. This categorization was then compared with angiographic findings, and the results were analyzed with receiver-operating-characteristic curves. Kappa statistics and agreement tables were computed to evaluate interobserver agreement. RESULTS: Interobserver agreement in the waveform analysis for the four interpreters was statistically significant (p < 0.001). The receiver-operating-characteristic areas produced by the observers indicated, however, that such waveform classification was not strongly predictive of renal artery stenosis. CONCLUSION: We conclude that substantial agreement in the interpretation of waveform morphology can be obtained between independent observers, and that such differences that do exist do not preclude the use of the pattern-recognition approach to waveform analysis. Even so, the specific application of this strategy to the waveform contours of early systole was not successful in predicting the presence or severity of renal artery stenosis.

Humans↗
PubMed1979

[Reconstructive surgery of the internal carotid artery (author's transl)].

Between 1970 and 1978 we performed 403 endarterectomies of the internal carotid artery on 330 patients. Operative morbidity (and mortality) depended on the severity of the ischemic cerebral damage at the time of the operation: stage I (137 operations):1.5% (0.7%); stage II (134 operations): 2.2% (3.7%); stage III (29 operations): 3.4% (10.3%); stage IV (103 operations): 3.9% (7.8%). According to the life-table analysis (average follow-up: 40 months) the rate of cured or improved patients amounts to 94% (operated at stage I), 85% (stage II), 84% (stage III) and 70% (stage IV).

Arterial Occlusive Diseases↗
PubMed1995

The influence of age on operative mortality and long-term relative survival following emergency abdominal aortic aneurysm operations.

OBJECTIVE: To study operative mortality and long-term survival following emergency operations for abdominal aortic aneurysm. DESIGN: Retrospective survey in a university hospital. MATERIALS: Two hundred and twenty-seven patients with median age 72 years, (17% women). METHODS: Founded on data from the Norwegian Registrar's Office, operative mortality and long-term survival was estimated using the life-table method. Expected survival for demographically matched subgroups was calculated from death rate tables issued by the Norwegian Central Bureau of Statistics. RESULTS: Operative mortality was 41% for the 175 patients with ruptured aneurysms and 17% for the 52 with imminent rupture. The 6-year survival rate was 61% for all the successfully operated patients, and not different from that of a demographically matched population. For the patients of 72 years or older the 6-year survival rate was 53%. This was equal to that of an age and sex matched population. The younger patients had an observed 6-year survival rate of 64%, which was significantly lower than the expected of 84%. The standard mortality rate for this group was 2.25. No statistically significant difference in long-term survival was detected between the two age groups. CONCLUSIONS: Age at the time of the operation for a symptomatic abdominal aortic aneurysm does not seem to influence long-term survival. Consequently, younger patients experience a higher relative mortality compared to the older.

Adult↗
PubMed1998

Carotid endarterectomy and contralateral internal carotid artery occlusion: perioperative risks and long-term stroke and survival rates.

BACKGROUND: The aim of this article was to analyze the perioperative mortality and stroke risk rates and late benefits of carotid endarterectomy (CE) contralateral to an occluded internal carotid artery (ICA), on the basis of our surgical experience from July 1990 to June 1996. METHODS: In 57 (14.7%) of 336 patients undergoing 388 CEs, the contralateral ICA was occluded (group I). All operations were performed under general anesthesia with selective shunting based on electroencephalographic criteria. Shunting was used in 36 (63.1%) of 57 revascularizations in group I and 47 (14.2%) of 331 operations performed on the remaining 279 patients with patent contralateral ICAs (group II) (p < 0.001). RESULTS: Perioperative strokes occurred in two patients (3.5%) in group I and three patients (1%) in group II (difference not significant). The only perioperative death, which occurred in one patient (1.7%) in group I, was the result of a perioperative stroke; two patients (0.7%) in group II died within 30 days of operation (difference not significant). Life-table cumulative stroke-free rates at 1, 3, and 5 years were 95%, 95%, 95% in group I and 98.8%, 98.2%, and 98.2% in group II, respectively (p = 0.272). Life-table cumulative survival rates at 1, 3, and 5 years were 97.5%, 94.2%, and 78.1% in group I and 99.2%, 94.8%, and 71.7% in group II, respectively (p = 0.306). CONCLUSIONS: The results of this analysis indicate that CE contralateral to an occluded ICA can be performed with acceptable perioperative mortality and stroke risk rates and late stroke-free and survival rates comparable to those seen in patients without contralateral ICA occlusion who have undergone operation. Nevertheless, we think it is misleading to imply that the risks of operating on the two groups are the same. Moreover, because no late stroke-related death occurred in patients with contralateral ICA occlusion, it would appear that superior late stroke-free rates did not translate into a prolonged survival advantage.

Aged↗
PubMed1982

[An operated case of cervical spontaneous hematomyelia].

We have reported a case of cervical spontaneous hematomyelia caused by cavernous hemangioma. A 47-year-old woman experienced a sudden onset of pain in the neck on 5 December 1979. One week after the onset she began to have tetraparesis. There was a rapidly increasing weakness of the extremities and she was referred to our department on 25 December 1979. At the time, the positive neurological findings were flaccid tetraplegia, bilateral loss of all sensory perception below the C4 level and urinary retention. Chest x-ray films demonstrated an elevation of right diaphragma. Roentgenograms of the cervical spine were normal. Emergency myelography via cisternal puncture revealed a central filling defect at the level of C3-C5. But there was no displacement of dentate ligament on lateral view, suggesting an intramedullary mass lesion. Laminectomy from C2 to Th1 and evacuation of the intramedullary blood clot at C3-C5 level were performed successfully. Microscopic examination of clots revealed cavernous hemangioma. The postoperative course was uneventful and the patient gradually improved in her motility. In the review of the literature including our case, vascular malformations are the commonest cause of spontaneous hematomyelia. They are found 12 out of 18 cases (Table 1). The symptoms of spontaneous hematomyelia are characterized by sudden onset of pain and rapid development of long tract sign in a previously asymptomatic individual. Operated cases are summarized in table 2. Good operative results are obtained 6 out 9 cases. We will emphasize that in a case of spontaneous hematomyelia with acute progression of transverse myelopathy, early diagnosis and operation are extremely important, and for this purpose, myelography is considered to be one of the most useful examinations.

Diagnosis, Differential↗