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PubMed2000

One-stage Duhamel-Martin procedure for Hirschsprung's disease: a 5-year follow-up study.

BACKGROUND/PURPOSE: With the introduction of the Endo-GIA stapling device the 1-stage Duhamel-Martin procedure became feasible for neonates and infants. Early results were promising. So far there were no meaningful data on the long-term functional results. This study shows the 5-year follow-up results after 1-stage Duhamel-Martin procedure for Hirschsprung's disease in neonates and infants. The results are compared with a historical group of patients from the same institution undergoing a 3-stage procedure. METHODS: Between September 1991 and December 1993 Hirschsprung's disease was diagnosed in 29 children. In 22 of them the disease was found within the first 2 months of life. In 19 children aganglionosis was restricted to the rectosigmoid colon. In 10 the innervation disturbance extended further, twice with involvement of the distal ileum. Initial treatment consisted of daily rectal irrigation. Postoperative follow-up on a regular out-clinic basis was 6 years (range, 5 to 7 years). Patients were scored for fecal continence, soiling, the use of laxatives, cannulae or rectal irrigation, enterocolitis, gain of body weight, and length. RESULTS: There were no intraoperative complications. The median postoperative stay was 7.7 days. Seven children encountered complications for which admission was necessary. Ultimately, 15 children have normal spontaneous defecation. Eight children display irregular soiling, without using laxatives. At 5-year follow-up 6 children are still on some sort of laxative or rectal irrigation. Mean growth and body weight is along the P50 and P50 to 90, respectively. These functional results are no different from those in the patients after 3-stage Duhamel-Martin procedure. CONCLUSIONS: There appears to be no difference in functional outcome after 1- or multiple-stage Duhamel-Martin procedure for Hirschsprung's disease after 5 to 7 years. The majority of children seem to fare well with restrictive need of laxatives. The advantage of a 1-stage procedure is the prevention of stoma-related complications, 1 or 2 additional operations, and extra scar formation.

Digestive System Surgical Procedures↗
PubMed2003

Long-term results of Rehbein's procedure: a retrospective study in German-speaking countries.

AIM: In contrast to other countries, no collective study of Rehbein's procedure in German-speaking nations has been performed. Therefore, our intention was, analogously to Goto and Ikeda's (10) Japanese study in 1984, Kleinhaus's (13) study on Swenson's procedure in 1979, Bourdelat's (2) French-Canadian investigation into Duhamel's technique in 1997 and Martuciello's (11) and Teitelbaum's (16) follow-up in the year 2000, to perform a follow-up study of Rehbein's technique of deep anterior resection. METHODS: The data of 200 patients from 22 German-speaking centers in Switzerland, Austria and Germany were collected. These data were gathered by questionnaire and the children were followed up in the individual participating hospitals for at least 3.5 years after the procedure. The procedure was performed between 1993 and 1997, over a 5-year period. The questionnaire contained 74 items including anamnestic data, diagnostic postoperative treatment and reoperations. RESULTS: Concerning the incidence of anastomotic leaks and resolving anastomotic strictures there was no significant difference between the results in our series and those of the collective analyses made by Hofmann von Kap-herr (7), Holschneider (9) and Sherman (18). In 6.6 % of the 191 patients an anastomotic leak and in 9.9 % a rectal stricture, which had to be dilated, was observed. Concerning late complications, 22.8 % of the children suffered from constipation, 4.3 % from encopresis, 10.6 % from enterocolitis and only 0.5 % from enuresis. The frequency of constipation diminishes over the years. A comparison of the different large series in the literature clearly shows that the incidence of constipation is higher after Rehbein's procedure and the frequency of urinary incontinence and encopresis higher following Swenson's, Soave's and Duhamel's techniques. The incidence of enterocolitis is less after Rehbein's procedure than after Swenson's, Soave's and Duhamel's techniques. CONCLUSIONS: The different results in the literature are due to the individual experience of the author, the very different follow-up methods and the date of follow-up. Therefore, the different results are hard to compare with our study. Nevertheless, Rehbein's anterior resection still could be presented as an adequate and important method to treat Hirschsprung's disease.

Austria↗
PubMed2004

[Filtering glaucoma surgery as outpatient procedure].

BACKGROUND: While cataract surgery is nowadays performed routinely as an outpatient procedure, performing filtering glaucoma surgery under these conditions remains questionable due to the more demanding perioperative management. PATIENTS AND METHODS: Outpatient filtering glaucoma surgery (trabeculectomy and combined phakoemulsification and trabeculectomy (phakotrab)) is performed at the Ophthalmology Department of Kantonsspital Winterthur when requested by the patient. This paper provides a retrospective review of all outpatient filtering glaucoma procedures performed in the last three and a half years. RESULTS: Forty-six filtering procedures (21 trabeculectomies and 25 phakotrabs) were performed in 45 eyes of 40 patients (50 - 84 years) as outpatient procedures. Mitomycin C was administered in 16/21 trabeculectomies and in 7/25 combined procedures. In the trabeculectomy group, intraocular pressure (IOP) was surgically lowered from 23.3 +/- 7.2 mm Hg (under 2.4 +/- 0.8 IOP-lowering medications) to 12.7 +/- 3.5 mm Hg (20/21 patients without medication). In the combined group, IOP was lowered from 20.8 +/- 6.3 (under 2.0 +/- 0.7 medications) to 13.7 +/- 2.7 mm Hg (only 5/25 patients still requiring IOP-lowering medications). In the latter group, the best corrected visual acuity was below 20/40 only in 2 eyes due to advanced glaucomatous optic atrophy. One patient developed relative intraocular hypotony (IOP 6 mm Hg), one patient required needling + 5-fluorouracil injection and one patient required surgical revision of the trabeculectomy after 14 months. DISCUSSION: Adequate patient selection and refined surgical technique (tight wound closure and releasable sutures or argon laser suturolysis) allow performing filtering glaucoma surgery as an outpatient procedure. Extended post-operative care during the first 2 months is the key for IOP-lowering success.

Aged↗
PubMed2006

Virtual simulation of neuroendoscopic procedures: early clinical experience with ventricular lesions.

BACKGROUND: Virtual endoscopy (VE) is a new and promising imaging technology. Applied to neuroendoscopy it allows preoperative simulation of a procedure and evaluation of the individual intraventricular anatomy in selected cases. Along with neuronavigation and real time intraoperative imaging, VE is expected to improve the safety and efficacy of neuroendoscopic procedures. PATIENTS AND METHODS: Between April 2003 and February 2004 VE simulation was performed in 13 randomly selected patients subjected to endoscopic procedures. Pathological entities included 4 cases with aqueduct stenosis, 4 with suprasellar arachnoid cysts, 2 tumors of the posterior third ventricle, 1 colloid cyst, 1 hyperplasia of the choroid plexus and 1 case with multiloculated hydrocephalus due to intraventricular septations. In 8 patients VE was accomplished preoperatively, in another 5 it was done after the operation, using data sets from neuronavigation imaging planning in 4 patients, and in one case using postoperative imaging studies. T (1)-weighted 3D image sets were acquired on a 1.5 T GE Genesis SIGNA MR scanner and VE reconstruction was performed using the General Electric Navigator software. The VE images were compared with the real images obtained during the endoscopic procedures and evaluated for their impact on the planning of the operative approach. RESULTS: VE implementation succeeded in all 13 patients. Major neuroanatomic reference structures were easily recognizable in all cases. Membranous structures such as the thinned floor of the third ventricle or cyst walls were identifiable in only 46 % of the cases. In 6 cases (46 %) VE showed anatomical variants and details relevant for the endoscopic procedure that were not identified on conventional MR images. CONCLUSIONS: VE has proved to be an important adjunct to the preoperative planning of neuroendoscopic procedures and its routine application is suggested.

Adolescent↗
PubMed2003

Procedures for pelvic organ prolapse in the United States, 1979-1997.

OBJECTIVE: The objective of our study was to describe national rates of surgery for pelvic organ prolapse. STUDY DESIGN: We used the National Hospital Discharge Survey, a federal database that samples inpatient hospitals in the United States. Data from 1979 to 1997 were analyzed for diagnoses and procedures coded with the ICD-9-CM classification system. Age-adjusted rates were calculated by using the 1990 census population and compared for change over time by using the Score test for linear trend. RESULTS: Approximately 200,000 women undergo inpatient procedures for prolapse in the United States each year, ranging from 165,000 in 1988 to 226,000 in 1979. There was a significant decrease in the overall age-adjusted rate of procedures performed over the study period, from 2.2 to 1.5 procedures per 1000 women (P =.01). The rate of prolapse procedures for women younger than 50 years decreased by more than half (1.9 to 0.8 per 1000 women, P <.001), whereas the rate remained stable in women who were aged 50 years and older (2.7 to 3.3 per 1000 women, P =.5). CONCLUSION: Prolapse procedures are performed very frequently in the United States, although the rate has decreased slightly over time.

Adult↗
PubMed2001

Volume standards for high-risk surgical procedures: potential benefits of the Leapfrog initiative.

BACKGROUND: As part of a broader effort aimed at improving hospital safety, a large coalition of employers, the Leapfrog Group, will soon require hospitals caring for their employees to meet volume standards for 5 high-risk surgical procedures. We estimated the potential benefits of full nationwide implementation of these volume standards. METHODS. Using data from Nationwide Inpatient Sample and other sources, we first estimated the total number of each of the 5 procedures-coronary-artery bypass graft, abdominal aortic aneurysm repair, coronary angioplasty, esophagectomy, and carotid endarterectomy-performed each year in hospitals in US metropolitan areas. (Leapfrog exempts hospitals in rural areas to avoid access issues.) We then projected the effectiveness of volume standards (in terms of relative risks of mortality) for each procedure using data from a published structured literature review. RESULTS: With full implementation nationwide, the Leapfrog volume standards would save 2581 lives. Of the procedures, volume standards would save the most lives with coronary-artery bypass graft (1486), followed by abdominal aortic-aneurysm repair (464), coronary angioplasty (345), esophagectomy (168), and carotid endarterectomy (118). In our estimates of the number of lives saved, we considered assumptions about how many patients would be affected and the effectiveness of volume standards (ie, strength of underlying volume-outcome relationships with each procedure). CONCLUSIONS: If the Leapfrog volume standards are successfully implemented, employers and health-care purchasers could prevent many surgical deaths by requiring hospital volume standards for high-risk procedures.

Humans↗
PubMed2006

Socioeconomic inequities in invasive cardiac procedures among patients with incident angina pectoris or myocardial infarction.

AIMS: In many countries, systematic socioeconomic disparities have emerged in the use of invasive cardiac procedures among myocardial infarction patients and hospitalized coronary patients. This study prospectively examined socioeconomic differences in the use of cardiac procedures in a national cohort of incident coronary patients. METHODS: The data were based on individual register linkages among 49,846 patients with incident angina pectoris (AP) or myocardial infarction (MI) during one-year follow-up in 1995-98 in Finland. Socioeconomic differences in invasive coronary procedures were examined using proportional hazard models. RESULTS: The analyses showed that women, AP patients, and persons with lower socioeconomic status received fewer procedures during the one-year follow-up than men, MI patients, and those with higher socioeconomic status. Socioeconomic differences in the utilization of cardiac procedures were similar in both AP and MI groups, among both men and women, and by all socioeconomic indicators: social class, education, and income. Disparities were already emerging after the 28-day follow-up among men and women in both patient groups, and they persisted throughout the study period. Controlling for disease severity, comorbidity, and hospital district did not modify the results. CONCLUSIONS: Socioeconomic disparities in receiving invasive coronary procedures among AP patients without MI were similar to those in MI patients.

Aged↗
PubMed1999

Surveillance of antimicrobial prophylaxis for surgical procedures.

OBJECTIVE: To assess the practice of antimicrobial prophylaxis for surgical procedures in eight surgical departments in a 550-bed teaching hospital. METHODS: A list of all major procedures performed in our hospital, with recommendations for prophylaxis based upon the literature, has been distributed since 1993 and is updated periodically. The practice of surgical prophylaxis between January 1 and March 31, 1996, was examined by assessing four variables: (1) Did the particular procedure justify prophylaxis, and was it provided? (2) Was timing optimal, ie, within 1 hour prior to surgery? (3) Was the appropriate antimicrobial selected? (4) Was duration optimal, ie, < or =24 hours? RESULTS: During the study period, 2,117 operations were performed, of which 1,631 (77%) were reviewed. Sixty-six percent were clean surgery, 28% clean-contaminated, and 6% contaminated; 72% of procedures were elective, 28% emergencies. Of 1,631 operations requiring prophylaxis, 1,142 (70%) received it, 489 (30%) did not. Of 1,631 patients, 1,392 (85%) received appropriate care: 929 (67%) appropriately received prophylaxis, and 463 (33%) appropriately did not receive prophylaxis. Of 955 patients who received prophylaxis, 26 (3%) did so inappropriately. Of 1,142 patients who should have received prophylaxis, 213 (19%) did not receive it. Female gender, clean surgery, elective operations, and infrequently performed procedures were all significant indicators of inappropriately withheld prophylaxis (P<.001). In addition, the rate of appropriately provided prophylaxis varied between departments from 71% to 97% (P<.001). Assessment of the 929 procedures for which prophylaxis was justified and given revealed that 100% of patients received it on time, the choice of antimicrobial was appropriate in 95% of cases, and duration was < or =24 hours in 91%. CONCLUSIONS: Audits of surgical prophylaxis are expected to detect different errors in different institutions. Conducting audits of surgical prophylaxis probably should be part of the routine activity of infection control teams. Feeding the information back to surgeons could improve adherence to recommended guidelines and might contribute to reduced wound infection rates.

Adult↗
PubMed2003

Is telesurgery a new reality? Our experience with laparoscopic and percutaneous procedures.

BACKGROUND: Minimally invasive surgery offers many advantages, but its correct practice is associated with a steep learning curve. Telesurgery allows a surgeon at a remote site to guide and teach surgeons at a primary site by utilizing robotic devices, telecommunications, and video technology, thereby reducing complications. PATIENTS AND METHODS: From September 1998 to July 2000, 17 procedures were telementored between two sites 9230 km apart: a primary operating room at the Policlinico Casilino "Tor Vergata" University of Rome and a remote site at the Johns Hopkins Medical Institutions in Baltimore. Of these procedures, 14 were laparoscopic cases: 8 spermatic vein ligations, 2 retroperitoneal renal biopsies, 3 simple nephrectomies, and 1 pyeloplasty. Three procedures were carried out to obtain percutaneous renal access. All procedures were performed with the help of two robots: the first robot, AESOP, for the orientation of the laparoscope, and the second one, PAKY, to perform the percutaneous renal access. In addition to the robotic device, the system provided four ISDN lines, a PC with dedicated software to manage the connection, audio and video connections, an external video camera with a panoramic view of the operating room, and remote control of the electrocautery and the Telestrator. RESULTS: All the procedures were accomplished with an uneventful postoperative course. Ten operative cases were telementored successfully. In five cases, it was not possible to establish a connection to the remote site, and two procedures were converted to open surgery because of intraoperative complications. The time delay of the image transmission was <1 second. CONCLUSION: This preliminary experience has demonstrated the feasibility of international telementoring. It could provide education to surgeons and decrease the likelihood of complications attributable to inexperience with new techniques.

Humans↗
PubMed1987

Constraints on the performance of minor surgery by family physicians: study of a 'mock' skin biopsy procedure.

Despite the availability of a procedure room equipped for the performance of common surgery procedures, physicians in a family medicine training programme have reported that minor surgery training objectives are not being accomplished. To examine this issue, the frequency of minor surgery procedures was audited among 357 randomly selected medical records. The frequency of documented sigmoidoscopy in this group of active patients over the age of 50 years was 4.8%. A similar low frequency for the performance of skin biopsy was also observed. All 15 senior residents participated in an attitude survey and a timed exercise in which they sought to find the necessary items for performance of a skin biopsy. In a questionnaire the group agreed that sigmoidoscopy and skin biopsies were procedures appropriate for their family practice goals. In their offices, these residents required over nine minutes to partially locate equipment chosen for skin biopsy. The attitude survey revealed few constraints other than insufficient time to perform indicated elective procedures. Further study of procedure room utilization and family physicians' office surgery skills is recommended.

Attitude of Health Personnel↗
PubMed2006

Associations between hospital and surgeon procedure volumes and patient outcomes after ovarian cancer resection.

BACKGROUND: Strong associations between provider (i.e., hospital or surgeon) procedure volumes and patient outcomes have been demonstrated for many types of cancer operation. We performed a population-based cohort study to examine these associations for ovarian cancer resections. METHODS: We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to identify 2952 patients aged 65 years or older who had surgery for a primary ovarian cancer diagnosed from 1992 through 1999. Hospital- and surgeon-specific procedure volumes were ascertained based on the number of claims submitted during the 8-year study period. Primary outcome measures were mortality at 60 days and 2 years after surgery, and overall survival. Length of hospital stay was also examined. Patient age at diagnosis, race, marital status, comorbid illness, cancer stage, and median income and population density in the area of residence were used to adjust for differences in case mix. All P values are two-sided. RESULTS: Neither hospital- nor surgeon-specific procedure volume was statistically significantly associated with 60-day mortality following primary ovarian cancer resection. However, differences by hospital volume were seen with 2-year mortality; patients treated at the low-, intermediate-, and high-volume hospitals had 2-year mortality rates of 45.2% (95% confidence interval [CI] = 42.1% to 48.4%), 41.1% (95% CI = 38.1% to 44.3%), and 40.4% (95% CI = 37.4% to 43.4%), respectively. The inverse association between hospital procedure volume and 2-year mortality was statistically significant both before (P = .011) and after (P = .006) case-mix adjustment but not after adjustment for surgeon volume. Two-year mortality for patients treated by low-, intermediate-, and high-volume surgeons was 43.2% (95% CI = 40.7% to 45.8%), 42.9% (95% CI = 39.5% to 46.4%), and 39.5% (95% CI = 36.0% to 43.2%), respectively; there was no association between 2-year mortality and surgeon procedure volume, with or without case-mix adjustment. After case-mix adjustment, neither hospital volume (P = .031) nor surgeon volume (P = .062) was strongly associated with overall survival. CONCLUSION: Hospital- and surgeon-specific procedure volumes are not strong predictors of survival outcomes following surgery for ovarian cancer among women aged 65 years or older.

Aged↗
PubMed2005

Financial implications of a hospital's specialization in rare physiologically complex surgical procedures.

BACKGROUND: The authors previously identified a hospital that has a unique role in its region for surgical care. In children aged 0-2 yr, the hospital performed 64% of all physiologically complex procedures statewide (>or= 8 American Society of Anesthesiologists Relative Value Guide basic units). For all age groups combined, 48% of the physiologically complex procedures performed at that hospital were rare, defined as < 1/workday statewide. METHODS: The authors tested the hypothesis that financially important differences can result from performing relatively large numbers of such specialized procedures. Methods were developed to compare contribution margin (revenue from facility and professional fees minus variable costs) per operating room hour (CM/OR hour) between patient groups and different types of surgical procedures. RESULTS: CM/OR hour was significantly larger by a financially important amount (> 250 dollars/OR hour) for pediatric versus geriatric patients (P <or= 0.002), primarily because of higher professional reimbursements, with no difference in hospital reimbursements. Unexpectedly, CM/OR hour was also significantly greater by at least 250 dollars when a rare procedure was involved (P < 0.001 for all ages combined), primarily because of greater hospital reimbursements. For cases involving implant charges of 10,000 dollars or greater, overall CM/OR hour was negative because increased revenues did not compensate for the high variable costs. CONCLUSIONS: Other hospitals can use these methods to perform a similar analysis of the financial impact of those patient populations or surgical procedures that are unique to their own roles in their regional healthcare systems, and to identify the sources of financial losses and gains experienced by the hospital.

Child↗
PubMed2002

Hospital and surgeon procedure volume as predictors of outcome following rectal cancer resection.

OBJECTIVE: To compare surgeon and hospital procedure volume as predictors of outcomes for patients with rectal cancer. SUMMARY BACKGROUND DATA: Although a "volume-outcome" relationship exists for several major cancer operations, the impact of procedure volume on outcomes following rectal cancer surgery remains uncertain, and it has not been determined whether hospital or surgeon volume is a more important predictor of outcomes. METHODS: A retrospective population-based cohort study utilizing the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database identified 2,815 rectal cancer patients aged 65 and older who had surgery for a primary tumor diagnosed in 1992-1996 in a SEER area. Hospital- and surgeon-specific procedure volume was ascertained based on the number of claims submitted over the 5-year study period. Outcome measures were mortality at 30 days and 2 years, overall survival, and the rate of abdominoperineal resections. Age, sex, race, comorbid illness, cancer stage, and socioeconomic status were used to adjust for differences in case mix. RESULTS: Neither hospital- nor surgeon-specific procedure volume was significantly associated with 30-day postoperative mortality or rates of rectal sphincter-sparing operations. Although an association between hospital volume and mortality at 2 years was evident, this finding was no longer significant once surgeon-specific volume was controlled for. In contrast, surgeon-specific volume was associated with 2-year mortality and remained an important predictor even after adjustment for hospital volume. Surgeon volume was also better than hospital procedure volume at predicting long-term survival. CONCLUSIONS: Surgeon-specific experience as measured by procedure volume can have a significant impact on survival for patients with rectal cancer.

Aged↗
PubMed2004

Tension-free vaginal tape procedures in women with stress urinary incontinence with and without co-existing genital prolapse.

PURPOSE OF REVIEW: Although the tension-free vaginal tape procedure has emerged as a feasible and effective alternative for a majority of urinary stress incontinence patients, the adaptation of the technique for genital prolapse has recently attracted much attention. This review focuses on the development of the tension-free vaginal tape procedure performed with transvaginal pelvic reconstructive surgery. RECENT FINDING: Articles since 1 April 2003 with older articles included for historical purposes were focused. Tension-free vaginal tape procedures used in prolapse surgery have mainly been performed according to the original technique. Adjustment of the vaginal tape is carried out after completion of the necessary prolapse procedures. The objective and subjective cure rate for urinary incontinence after tension-free vaginal tape with concurrent prolapse procedures is between 84.9 and 94%, and 67.3 and 88.6%, respectively. The mean complication rate, bladder perforation rate, transient urinary retention rate, period of catheterization and postoperative hospital stay are between 2.7 and 34%, 0 and 13%, 9 and 43%, 3.7 and 5.1 days, and 3.4 and 6.9 days, respectively. The implanted vaginal tape seems to 'give way' to the urethra and causes no urinary obstruction at least in studies with a short follow-up period. SUMMARY: The tension-free vaginal tape procedure performed with concurrent pelvic relaxation surgery appears to be a safe and effective treatment for urinary stress incontinence with co-existing vaginal pelvic prolapse. The implanted vaginal tape is prolapsed with the adjacent pelvic tissue, but the possibility of voiding dysfunction needs to be observed in a longer follow-up period.

Female↗
PubMed2003

Salvage frontal sinus surgery: the endoscopic modified Lothrop procedure.

OBJECTIVES/HYPOTHESIS: Until recent years, the osteoplastic flap with frontal sinus obliteration has been the gold standard for recalcitrant frontal sinusitis. The present series evaluated the role of the endoscopic modified Lothrop procedure, which has recently been advocated as an alternative. STUDY DESIGN: Prospective non-randomized interventional case series. METHODS: The study prospectively assessed 83 consecutive patients who underwent endoscopic modified Lothrop procedure. The mean age was 52.4 years (SD = 13.6 y) with a male-to-female ratio of 3:1. Patients had a mean of six previous sinus surgical procedures with 17 patients having undergone previous frontal sinus obliteration with mucocele formation. Seventy-six patients (91%) had frontal pain or headache as their primary presenting symptom, with 72 having nasal discharge. There were 14 patients who presented with 17 complications of frontal sinus disease. There were eight erosions of the posterior table of the frontal sinus with extension of the mucocele intracranially, seven orbital complications, and one cerebrospinal fluid leak. Twenty-four patients (30%) had fungus cultured from their sinuses at the time of surgery. RESULTS: Six of the 83 patients (7%) developed frontal ostium stenosis resulting in a 93% primary success rate after an average follow-up of 21.9 months (SD = 6.1 mo). These patients all underwent a revision modified Lothrop procedure and had a patent frontal ostium at their last review. Twenty-one patients (25%) developed recurrent symptoms, which were managed medically. Of these 21 patients, 9 with previously diagnosed fungal sinusitis developed mucosal changes again in their frontal sinuses, but their ostia have remained patent. Four patients have had recurrent infections in the frontal sinuses, and three patients with aspirin-sensitive asthma and polyps have developed polyps again in their frontal sinuses. Five patients continued to have frontal pain without radiological evidence of further frontal disease. No patients required an osteoplastic flap procedure. CONCLUSION: The endoscopic Lothrop procedure is a successful short-term management option for recalcitrant and complicated frontal sinusitis caused by a wide range of diseases.

Chronic Disease↗
PubMed1996

Variations by specialty in physician ratings of the appropriateness and necessity of indications for procedures.

The authors compare the appropriateness ratings and mutual influence of panelists from different specialties rating a comprehensive set of indications for six surgical procedures. Nine-member panels rated each procedure: abdominal aortic aneurysm surgery, carotid endarterectomy, cataract surgery, coronary angiography, and coronary artery bypass graft surgery/percutaneous transluminal coronary angioplasty (common panel). Panelists individually rated the appropriateness of indications at home and then discussed and re-rated the indications during a 2-day meeting. Subsequently, they rated the necessity of those indications scored by the group as appropriate. There were 45 panelists, including specialists (either performers of the procedure or members of a related specialty) and primary care providers, all drawn from nominations by their respective specialty societies. Main outcome measures included: individual panelists' mean ratings over all indications, mean change and conformity scores between rounds of ratings, and the percentage of audited actual procedures rated appropriate or necessary. Performers had the highest mean ratings, followed by physicians in related specialties, trailed by primary care providers. One fifth of all actual procedures were for indications rated appropriate by performers and less than appropriate by primary care providers. At the panel meetings, primary care providers and related specialists showed no greater tendency to be influenced by other panelists than did performers. Multispecialty panels provide more divergent viewpoints than panels composed entirely of performers. This divergence means that fewer actual procedures are deemed performed for appropriate or necessary indications.

Angioplasty, Balloon, Coronary↗
PubMedDate not supplied

Helping expand nurse practitioner students' clinical skills repertoire: learning minor procedures.

This course is immensely popular with students. Many express a sense of accomplishment in knowing that they have performed a specific procedure at least once before facing the requirement in the clinical setting. Students who complete the course have a firm foundation in minor procedures and are knowledgeable about indications, contraindications, and methods to perform the procedure before facing that first patient in the clinical setting. They have also accumulated a set of procedures, patient discharge instructions, and a bibliography that can be reviewed before performing a procedure for the first time in the clinical setting. Combining clinical hands-on skills with the experience of writing a step-by-step procedure reinforces learning and is a valuable skill that can be used in clinical practice after graduation. Although many of the students will only apply a portion of the skills they learn in this course, they express a significant boost in self-confidence, a decrease in anxiety level, a sense of accomplishment in their skills, and a definite edge in securing a nurse practitioner position in a competitive healthcare marketplace.

Educational Measurement↗
PubMed2004

Trans-obturator-tape procedure--"inside out or outside in": current concepts and evidence base.

PURPOSE OF REVIEW: Surgical treatment of female stress urinary incontinence has become very popular as a consequence of the good results given by the minimally invasive tension-free vaginal tape. This has attracted great attention from industry, resulting in a proliferation of new slings and different implantation techniques. This review focuses on published literature on the two trans-obturator procedures, outside in or inside out, recently described. RECENT FINDINGS: Tension-free vaginal tape was originally reported as a very safe procedure. However, analyses performed in Scandinavia and Austria and several clinical case reports have emphasized the risk of serious complications, related to the penetration of the retropubic space. Two new surgical approaches have been introduced maintaining the position under the mid-urethra of the tension-free vaginal tape but reducing or even eliminating complications related to the penetration of the retropubic space by placing the tape between the two obturator foramens, from outside to inside or from inside to outside. SUMMARY: Efficacy reported results are very close to those reported in most of the observational series of tension-free vaginal tape. Both trans-obturator procedures have been reported with very few complications. Anatomical dissections have shown that these two procedures can be very safe, but that the tip of the tunneller could injure the bladder, the urethra or the obturator pedicle. Surgeons have to respect the key points of the procedures. No evidence-based conclusion can yet be drawn on these two procedures. Long-term follow-up trials and tracker studies including very large cohorts of patients are needed.

Female↗