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PubMed2002

The importance of intraoperative angiographic findings for predicting long-term patency in coronary artery bypass operations.

BACKGROUND: The quality of anastomosis is the cornerstone in coronary artery bypass operations. Intraoperative coronary angiography confirms graft patency with the possibility to revise graft failure. The aim of this study was to describe the lesions found at "on-table" angiography, and to evaluate the significance of these immediate angiographic findings for the long-term patency. METHODS: A total of 57 grafts (42 left internal mammary artery grafts and 15 saphenous vein grafts) in 45 patients who underwent off-pump coronary artery bypass operations were included. On-table angiography was carried out with fixed angiographic equipment installed in the operating room. Follow-up angiographies were performed at 3 months and at 12 months. RESULTS: The most frequent finding in an on-table angiogram was spasm, which was not present at follow-up. Out of nine kinks, only one developed into a significant stenosis at follow-up. Of 44 grafts that were normal on-table, 37 (84%) were normal at the follow-up. Of 11 grafts with significant lesions on-table, eight (73%) were normal at the follow-up. Five percent of the grafts were revised because of the on-table angiography. CONCLUSIONS: On-table angiograms can be occasionally difficult to interpret because not all findings are important for later patency. Optimal results on-table predict good long-term results with a negative predictive value of 0.84, whereas significant lesions on-table have less impact on the follow-up results because the positive predictive value was only 0.38.

Adult↗
PubMed1995

Adjunctive mitomycin C in Molteno implant surgery.

PURPOSE: The authors assessed the efficacy of adjunctive intraoperative mitomycin C to produce lower intraocular pressures (IOPs) in patients with complicated glaucoma who underwent double-plate Molteno implantation. METHODS: A pilot series of 21 consecutive patients who underwent double-plate Molteno implantation with adjunctive intraoperative mitomycin C (0.5 mg/ml) for 5 minutes was compared with a historical control group who received Molteno implants without mitomycin C (n = 18). With failure defined as an IOP greater than 21 or less than 6 mmHg at two observations 1 month apart, the addition of medication, re-operation for glaucoma, or tube removal, a life-table analysis of IOP was performed on patients with at least 3 months' follow-up. RESULTS: Success in the mitomycin C group was higher (68% at 1 year) than the control group (17% at 1 year; P = 0.006). Loss of more than one line of vision (33%) and re-operation for complications (including flat anterior chamber, choroidal detachment, and tube blockage) (38%) were slightly but not significantly more frequent in the mitomycin C group than in the control group. CONCLUSION: This study suggests that intraoperative mitomycin C in conjunction with Molteno implant may offer a better chance of achieving target IOPs in the low teens in patients with complicated glaucoma than Molteno implantation alone.

Adult↗
PubMed1990

Malignant left-sided large bowel obstruction managed by subtotal/total colectomy.

Of 60 patients presenting with acute obstructing carcinoma of the left colon, 49 underwent immediate resection either by radical subtotal/total colectomy (31 patients, group I) or by radical segmental resection (18 patients, group II) of whom three had immediate anastomosis after on-table bowel irrigation and 15 had a planned staged procedure. The operative mortality rate was 3 per cent in group I and 11 per cent in group II (not a statistically significant difference). However, substantial differences were found for major morbidity (6 versus 44 per cent in groups I and II respectively; P less than 0.01) and mean length of hospital stay (17 days in group I versus 35 days in group II; P less than 0.05). All three patients who had on-table lavage developed anastomotic leaks which necessitated a second operation to form a stoma. Six patients (19 per cent) in group I required antidiarrhoeal medication in the immediate postoperative period. However, subsequent improvement in stool frequency was noted in all patients. It is concluded that subtotal/total colectomy is an acceptable means of managing patients with obstructing carcinoma of the left colon in that it is associated with a low morbidity and mortality rate and good functional results.

Aged↗
PubMed1987

Transluminal angioplasty versus conventional operation in the treatment of haemodialysis fistula stenosis: results from a 5-year study.

In this retrospective study we have used life table analysis to compare the results of 37 transluminal angioplasties with those of 37 conventional operations (thrombectomy, thrombendarterectomy with/without grafting, bypass) in the treatment of stenoses and occlusions of haemodialysis fistulae. There was no difference between the groups in terms of lesion morphology or the patients' age and sex. Cumulative patency rates for angioplasty and surgery, respectively, were 94.5 and 78.1 per cent after 1 week, 72.3 and 64.1 per cent after 1 month, 41.2 and 28.9 per cent after 5 months and 31.3 and 19.3 per cent after 1 year (X2 test, P less than 0.001). The difference is due mainly to a high percentage of early occlusions in the haemodialysis fistula stenoses is possible it achieves results which are at least as good as those of operation.

Actuarial Analysis↗
PubMed1989

[A sufentanil dosage study in general surgery].

Sufentanil is widely used for cardiac surgery in initial doses up to 15 micrograms/kg. It was expected that for general surgery much smaller doses would be appropriate. The aim of the study, therefore, was to find a dosage scheme for sufentanil that could be used in general surgery for operations lasting 1 h. METHODS. In 62 patients (Table 1), anesthesia was induced with 15 micrograms sufentanil and 0.2 mg/kg etomidate. According to a random group allocation, a bolus injection of sufentanil was administered 1 min before incision, so that the patients received 0.5, 1.0 or 1.5 micrograms/kg along with the initial dose. During maintenance anesthesia, repeat doses of 10 micrograms sufentanil were injected as required (rise in blood pressure and/or heart rate by more than 20%, or other stress signs i.e., sweating, movement). Intubation was facilitated by means of atracurium 0.5 mg/kg. Increments of 5-10 mg were given when needed. RESULTS. In the group of patients who had received 1.0 micrograms/kg, both the number requiring repeat doses, and the total number of repeat doses were significantly lower than in the 0.5 microgram/kg group. A further increase to 1.5 micrograms/kg did not prove to have any advantage and it led to a drop in blood pressure, that was more pronounced and of longer duration than in the other groups. CONCLUSION. A dose of 1.0 micrograms/kg, therefore, appeared to be the optimum initial dose in general surgery for operations lasting at least 1 h.

Abdomen↗
PubMed1997

Resection for cure of adenocarcinoma of the head of the pancreas: the greater Hartford experience.

BACKGROUND: Nationally, the results of pancreaticoduodenectomy for adenocarcinoma of the pancreas have improved. Therefore, we examined our experience with this operation. METHODS: A retrospective review of tumor registry data from four greater Hartford, Connecticut, hospitals identified 51 patients who underwent pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas between 1982 and 1992. RESULTS: The 30-day operative mortality rate for the group was 4%. Life table survival analysis revealed a five-year survival rate of 15% and a median survival of 15 months. Twelve patients had postoperative radiation therapy and chemotherapy. The median survival in this group was 36 months, significantly longer than that of the nonadjuvant therapy group (13 months, P < .02). No difference in operative mortality or ultimate survival was seen between the hospital with the largest experience and the three other hospitals. CONCLUSIONS: Pancreaticoduodenectomy can be performed safely at hospitals with relatively low pancreaticoduodenectomy volume. Survival rates are longer than in past reviews.

Adenocarcinoma↗
PubMedDate not supplied

[Treatment of losses of bone substance of the frontal region with outer table autogenic graft].

Ten patients with losses of frontal bone were operated with the use of bone grafts taken from the parietal area without craniotomy. In all patients the contour was restored without complications at the donor area. Results were evaluated clinically and radiologically one year later and no absorption was observed. We conclude that bone grafts from outer layer of parietal bone offer a satisfactory esthetic results. The morbidity at the donor area was not significant.

Adult↗
PubMed1982

Simultaneous bilateral intraocular surgery.

During the past ten years, the frequency of bilateral simultaneous intraocular surgery has increased and the majority have been cataract extractions. Two hundred and fifty-one patients have had this operation. The pre- and postoperative acuities and the complications have been tabled and the assessment indicates that this is a safe and successful approach considering the age of the patients and the associated pathology. There was no bilateral operative disaster. Of 232 patients whose post-operative acuities were recorded and are known, no patient had worse binocular acuity following bilateral simultaneous cataract extraction. Hospital time in the clinics, the ward and the operating theatre has been saved and the patients are more quickly returned to balanced binocular vision.

Aged↗
PubMed2006

A pretreatment table for the prediction of final histopathology after radical prostatectomy in clinical unilateral T3a prostate cancer.

OBJECTIVES: Partin tables are the most widely used tool to predict histopathologic stage after radical prostatectomy (RP) in organ-confined tumors. Such a predictive table in clinical T3 disease is still lacking. Our objective was to create a reference table for clinical unilateral T3a prostate cancer. PATIENTS AND METHODS: Between 1987 and 2004, 200 patients with clinical unilateral T3a disease underwent a RP and bilateral pelvic lymphadenectomy at our institution. No patient had received neoadjuvant treatment. Patients were divided into three prostate-specific antigen (PSA) subgroups ( 10-20 ng/ml, and >20 ng/ml) and two biopsy Gleason sum (GS) subgroups ( or=7 [4+3]). These parameters were used in the table as predictors for final histopathology. Margin and nodal status were also recorded. The multinomial log-linear regression analysis was used to construct the table. RESULTS: The table stratifies patients into six demarcated risk groups. In the first group, consisting of patients with PSA 20 and GS >or=7 (4+3), understaging was as high as 68% (44% pT3b and 22% pT4). Receiver operating characteristic analyses showed good accurate predictive ability of the table for seminal vesicle involvement and adjacent structure involvement, with moderate predictive ability for extraprostatic extension only. CONCLUSIONS: We present a table combining preoperative serum PSA and biopsy GS to predict histopathologic results in clinical unilateral T3a prostate cancer. The table may provide a basis for decision-making and patient counseling before treating this cancer.

Adult↗
PubMed1997

The results of transplantation of intercalary allografts after resection of tumors. A long-term follow-up study.

We reviewed the results of 104 intercalary allograft procedures that had been performed, between April 1974 and August 1992, in 100 patients, usually after resection of a segment of bone because of an osseous neoplasm. The median duration of follow-up was 5.6 years. Retention of the graft and return to essentially normal function were the measures of success and, on that basis, eighty-seven (84 per cent) of the 104 reconstructions were successful. Of the fifteen limbs in which the reconstruction failed, four were salvaged with insertion of a second allograft and three, with use of some other technique. Of the 104 allograft procedures, eight (including two in patients who had a recurrent tumor) were followed by an amputation; thus, the ultimate rate of salvage was 92 per cent for the entire series. Thirty-one grafts failed to unite at one junction with the host or both, within one year after the operation, and this necessitated eighty-one additional operative procedures to achieve a good result. Life-table regression analysis showed that age, gender, anatomical site, and length of the graft were not associated with significant differences in the over-all outcome. Infection (p = 0.0001); fracture (p = 0.002); stage of the lesion (p = 0.007); and use of adjuvant chemotherapy or radiation, or both (p = 0.008), all had an adverse effect on the survival of the allograft. Despite the relatively high rate of non-union that necessitated additional operations, these data indicate that transplantation of allografts for the treatment of intercalary defects has a high rate of success and usually results in a functional limb.

Adolescent↗
PubMed1999

Application of mortality prediction systems to individual intensive care units.

OBJECTIVE: To evaluate the predictive accuracy of the severity of illness scoring systems in a single institution. DESIGN: A prospective study conducted by collecting data on consecutive patients admitted to the medical intensive care unit over 20 months. Surgical and coronary care admissions were excluded. SETTING: Veterans Affairs Medical Center at Buffalo, New York. PATIENTS AND PARTICIPANTS: Data collected on 302 unique, consecutive patients admitted to the medical intensive care unit. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Data required to calculate the patients' predicted mortality by the Mortality Probability Model (MPM) II, Acute Physiology and Chronic Health Evaluation (APACHE) II and Simplified Acute Physiology Score (SAPS) II scoring systems were collected. The probability of mortality for the cohort of patients was analyzed using confidence interval analyses, receiver operator characteristic (ROC) curves, two by two contingency tables and the Lemeshow-Hosmer chi-square statistic. Predicted mortality for all three scoring systems lay within the 95 % confidence interval for actual mortality. For the MPM II, SAPS II and APACHE II, the c-index (equivalent to the area under the ROC curve) was 0.695 +/- 0.0307 SE, 0.702 +/- 0.063 SE and 0.672 +/- 0.0306 SE, respectively, which were not statistically different from each other but were lower than values obtained in previous studies. CONCLUSION: Although the overall mortality was consistent with the predicted mortality, the poor fit of the data to the model impairs the validity of the result. The observed outcome could be due to erratic quality of care, or differences between the study population and the patient population in the original studies. The data cannot be used to distinguish between these possibilities. To increase predictive accuracy when studying individual intensive care units and enhance quality of care assessments it may be necessary to adapt the model to the patient population.

APACHE↗
PubMed2003

Assessment of clinical utility of 18F-FDG PET in patients with head and neck cancer: a probability analysis.

The purpose of this study was to calculate disease probabilities based on data of patients with head and neck cancer in the register of our institution and to perform a systematic review of the available data on the accuracy of PET in the primary assessment and follow-up of patients with head and neck cancer. The pre-test probability of head and neck cancer among patients in our institutional data registry was assessed. Then the published literature was selected and appraised according to a standard protocol of systematic reviews. Two reviewers independently selected and extracted data on study characteristics, quality and accuracy. Accuracy data were used to form 2 x 2 contingency tables and were pooled to produce summary receiver operating characteristic (ROC) curves and summary likelihood ratios for positive and negative testing. Finally post-test probabilities were calculated on the basis of the pre-test probabilities of this patient group. All patients had cytologically or histologically proven cancer. The prevalence of additional lymph node metastases on PET in staging examinations was 19.6% (11/56), and that of locoregional recurrence on restaging PET was 28.6% (12/42). In the primary assessment of patients, PET had positive and negative likelihood ratios of 3.9 (2.56-5.93) and 0.24 (0.14-0.41), respectively. Disease probabilities were therefore 49.4% for a positive test result and 5.7% for a negative test result. In the assessment of recurrence these values were 3.96 (2.8-5.6) and 0.16 (0.1-0.25), resulting in probabilities of 49.7% and 3.8%. PET evaluation for involvement of lymph nodes had positive and negative likelihood ratios of 17.26 (10.9-27.3) and 0.19 (0.13-0.27) for primary assessment and 11.0 (2.93-41.24) and 0.14 (0.01-1.88) for detection of recurrence. The probabilities were 81.2% and 4.5% for primary assessment and 73.3% and 3.4% for assessment of recurrence. It is concluded that in this clinical setting the main advantage of PET is the ability to reliably rule out the presence of disease in both staging and restaging. Further research is required to derive probabilities for individual patients from sequential testing as applied in the diagnostic work-up of patients with head and neck cancer.

Adult↗
PubMed1998

The cluster of arachnoid diverticula in the occipital bone: report of two cases with literature review.

The authors report two cases of multicentric osteolytic lesions in the occipital bone without any history of head trauma. The excisional biopsy of the first case revealed that the lesion was multicentric but a continuous cavity with the subarachnoid space through various sizes of dural defect, and the cavities were covered by arachnoid lining. Together with the previously reported similar 5 cases, the characteristic common feature is multicentric osteolytic lesions in the occipital bone at advanced age without marginal sclerosis. "The cluster of arachnoid diverticula in the occipital bone (CADOB)" is probably the most appropriate term for these non-traumatic lesions with the following characteristics: elderly patients, occipital bone, midline, multiple, intact outer table, nonsclerotic margin and without history of trauma. Operation may not be indicated because of its non-progressive and benign nature.

Aged↗
PubMed1977

Carcinoma of the endometrium: radiation followed immediately by operation.

A prospective study was established in August, 1967, to treat all adenocarcinomas of the endometrium by protocols of preoperative radiation followed immediately by operation. Two hundred and ninety-five women have been treated, 220 of whom had Stage I disease. In these cases, factors known to be associated with survival were studied, and their influence upon survival was noted. Preoperative radium followed immediately by operation was the primary method of therapy. Life tables demonstrated a five-year survival rate of 91 per cent with a low complication rate in patients with Stage I disease. Cell type, degree of differentiation, and depth of myomentrial invasion were the primary factors influencing survival.

Adenocarcinoma↗
PubMed2005

Thrombectomy in HIV related peripheral arterial thrombosis: a preliminary report.

OBJECTIVES: To evaluate the limb salvage rate in patients undergoing thrombectomy for HIV related peripheral arterial thrombosis. METHODS: A prospective review of patients with HIV related peripheral arterial thrombosis managed at the Durban Metropolitan Vascular Service in Kwazulu-Natal South Africa over a 5-year (1998-2003) period. All patients underwent thrombectomy. RESULTS: Twenty-two patients (20 males) with HIV related peripheral arterial thrombosis (two upper limbs, 20 lower limbs) were included in the study. The median age was 36 years (24-46 years). All patients had rest pain and seven patients had gangrene (digital five, forefoot two). Seven patients had a short history of claudication before development of rest pain. Mean duration of symptoms was 30 days (1-120 days) with 10 patients presenting within 24 h. Most patients had a good general state of health and only three had clinical evidence of HIV infection. Ten patients who presented with threatened limbs from acute arterial occlusion were subjected to thrombectomy without any diagnostic investigations. Twelve patients who did not present with critical limb ischaemia had duplex ultrasonography, which showed arterial occlusion by a thrombus with normal proximal arteries. The striking features were the normal proximal vessels and absence of distal run-off. The search for an underlying cause, echocardiography in seven patients and coagulation screening in 10 patients, was always negative. All patients were subjected to thrombectomy with an on-table angiogram and received systemic heparin intra-operatively and deltaparin post-operatively. In 20 patients, duplex ultrasonography confirmed re-thrombosis within 48 h. Two patients remained with patent arteries. Most (16/20) patients who re-thrombosed required a major amputation and thrombectomy did not alter the level of amputation. The other four patients with re-thrombosis had symptomatic relief. Three patients died within 30 days of thrombectomy, all of HIV related complications. Overall the limb salvage rate was 6/22 (27%). CONCLUSION: Limb salvage rate following thrombectomy in HIV related peripheral arterial thrombosis is very low. Duplex ultrasonography appears to be an adequate radiological diagnostic investigation for these patients.

Adult↗
PubMed2004

Technique and considerations when using external fixation as a standard treatment of femoral fractures in children.

Femoral fractures in children can be treated effectively and with a low complication rate by using external fixation. However, as with most treatment modalities there is a learning curve to be considered. The aim of this paper is to report "tricks" and different considerations that we have learned to be of value based on experience gained during a prospective and consecutive study of 98 femoral fractures in children aged 3-15 years. Our experience is based on the use of a unilateral fixator with the option to apply axial dynamisation. Traction prior to operation is not needed if the child is operated on within 24h. During surgery a traction table will prevent significant malrotation and facilitate reduction prior to insertion of the pins. Four 4 or 5mm pins are sufficient for adequate stability in children. Transverse skin incisions are preferable for pin insertion as the scars become smaller and the soft tissue irritation during activity is less when compared with longitudinal incisions. Unrestricted weight-bearing can be allowed. A nihilistic approach to pin site care with daily showers is as effective as more aggressive treatment with local antiseptics. Pin infections can occur but are mild and can be treated locally or with a short period of antibiotics taken orally. Pin-loosening and deep infections are very uncommon. By using external fixation, malunion, overgrowth or delayed union can almost be avoided completely. Re-fractures are rare and occur only after significant trauma. Treatment time is relatively short. No physiotherapy or further protection of the leg is necessary during or after healing.

Adolescent↗
PubMed2004

Combination treatment of venous thoracic outlet syndrome: open surgical decompression and intraoperative angioplasty.

OBJECTIVE: Residual subclavian vein stenosis after thoracic outlet decompression in patients with venous thoracic outlet syndrome is often treated with postoperative percutaneous angioplasty (PTA). However, interval recurrent thrombosis before postoperative angioplasty is performed can be a vexing problem. Therefore we initiated a prospective trial at 2 referral institutions to evaluate the safety and efficacy of combined thoracic outlet decompression with intraoperative PTA performed in 1 stage. METHODS: Over 3 years 25 consecutive patients (16 women, 9 men; median age, 30 years) underwent treatment for venous thoracic outlet syndrome with a standard protocol at 2 institutions. Twenty-one patients (84%) underwent preoperative thrombolysis to treat axillosubclavian vein thrombosis. First-rib resection was performed through combined supraclavicular and infraclavicular incisions. Intraoperative venography and subclavian vein PTA were performed through a percutaneous basilic vein approach. Postoperative anticoagulation therapy was not used routinely. Venous duplex ultrasound scanning was performed postoperatively and at 1, 6, and 12 months. RESULTS: Intraoperative venography enabled identification of residual subclavian vein stenosis in 16 patients (64%), and all underwent intraoperative PTA with 100% technical success. Postoperative duplex scans documented subclavian vein patency in 23 patients (92%). Complications included subclavian vein recurrent thrombosis in 2 patients (8%), and both underwent percutaneous mechanical thrombectomy, with restoration of patency in 1 patient. One-year primary and secondary patency rates were 92% and 96%, respectively, at life-table analysis. CONCLUSIONS: Residual subclavian vein stenosis after operative thoracic outlet decompression is common in patients with venous thoracic outlet syndrome. Combination treatment with surgical thoracic outlet decompression and intraoperative PTA is a safe and effective means for identifying and treating residual subclavian vein stenosis. Moreover, intraoperative PTA may reduce the incidence of postoperative recurrent thrombosis and eliminate the need for venous stent placement or open venous repair.

Adult↗
PubMed2003

Efficacy and pregnancy outcome of two methods of semen preparation for intrauterine insemination: a prospective randomized study.

OBJECTIVE: To examine pregnancy outcome with two methods of semen preparation for intrauterine insemination (IUI). DESIGN: Prospective and randomized study. SETTINGS: Academic tertiary center. PATIENT(S): Three hundred eleven couples undergoing 676 consecutive cycles of assisted conception using IUI. INTERVENTION(S): Semen samples collected for IUI were randomized to wash only or density gradient centrifugation (DGC) processing. MAIN OUTCOME MEASURE(S): Various prepreparation and postpreparation semen parameters were used for IUI. The influence of the method of semen processing, and impact of various semen parameters and female factors on pregnancy were examined by receiver operating characteristics (ROC) curves, logistic regression, and life table analysis. RESULT(S): Of the 676 cycles, 88 resulted in conception leading to an overall clinical pregnancy rate of 13.0% per cycle and 28.3% per patient with a miscarriage rate of 34.0%. Eighty-eight percent of pregnancies occurred in the first three cycles of IUI and 95.5% within the first four cycles. The pregnancy rate for wash only was 11.6% (37 of 319) and the rate for DGC was 14.3% (51 of 356). However, in samples with <22 million motile sperm in the inseminate, pregnancy rates were 4% for wash and 18% for DGC. The woman's age for both methods and the percentage of sperm in the original semen with a velocity of > or =80 micro m/s for the wash method influenced pregnancy outcome. CONCLUSION(S): Although samples with an acceptable number of motile sperm can be processed efficiently by wash only, poor quality semen samples should be processed using DGC.

Adult↗