Adjustable Procedure Research Articles

Adjustable and non-adjustable strabismus surgery: a retrospective case-matched study

Adjustable suture strabismus surgery was introduced to improve results in unpredictable strabismus cases. However, its usage is increasing and in some centres is routine. The present authors propose that the routine use of the adjustable suture technique can only be justified if it can be shown to confer an advantage to the patient. In a retrospective analysis of matched data, they compared the results of their adjustable with non-adjustable strabismus surgery. The adjustable suture procedures performed during a 5-year period, on non-thyroid eye disease patients, were matched to non-adjustable cases according to the type and aetiology of strabismus and the magnitude of deviation. Pairs were matched as closely as possible according to age and strabismus surgery history. All cases were incomitant. The surgical results of the two groups were analysed with regard to the pre-operative and post-operative angles of deviation, the post-operative drift, and a successful outcome, pre-defined by carefully selected criteria. Twenty-six cases were analysed in each of the two groups. Mean pre- and post-operative angles of deviation showed no significant difference between the two groups. ‘Success’ rates were 81% in the adjustable group and 88% in the non-adjustable group. Given that the success rate of the two techniques is similarly high, a much larger study is required to detect a difference in results, with statistical significance. The authors conclude that there is currently insufficient evidence that patients, without thyroid eye disease, benefit from the longer and potentially uncomfortable procedure of adjustable suture strabismus surgery to support its rapidly growing use and that a prospective randomised controlled trial is indicated.

Laparoscopic adjustable gastric banding: initial Tasmanian experience.

The laparoscopic adjustable gastric band (LAGB) is a minimally invasive, adjustable and reversible bariatric procedure. The present paper reports an initial 2 year experience at Royal Hobart Hospital, Tasmania. Between February 1999 and June 2001, 207 patients underwent LAGB insertion (176 female, 31 male). The mean age was 43 years (range: 16-74 years). Mean preoperative weight was 125 kg (range: 83-210 kg) and mean body mass index (BMI) was 45.9 (range: 32.6-67.0). The Bioenterics LAGB (Inamed, Chullora, NSW, Australia) was used in all cases. The average follow up was 17 months (range: 3-24 months). Three patients were lost to follow up (1.5%). The average weight loss was 12.4 kg at 3 months, 25.3 kg at 1 year and 34.8 kg at 2 years. The average BMI was reduced from 45.9 preoperatively to 41.3 at 3 months, 36.9 at 1 year and 33.5 at 2 years. Reoperation for band slippage occurred in 24 patients (11%), and the injection reservoir required changes in 22 patients (11%). There were three perforations while inserting the LAGB, two non-fatal pulmonary emboli (1%) and two cases of deep vein thrombosis (1%). There has been no mortality. Laparoscopic adjustable gastric banding is a safe and effective method of achieving significant (P < 0.0001) weight reduction in the morbidly obese.

Evolution of a paradigm for laparoscopic adjustable gastric banding

The first human laparoscopic adjustable gastric banding procedure, using the LAP-BAND device (INAMED Health, Santa Barbara, CA), was performed on September 1, 1993. Because of its minimal invasiveness, reversibility, and adjustability, it is considered a breakthrough in bariatric surgery. Placement of the LAP-BAND is the least invasive operative procedure that can be offered to patients with morbid obesity. The technique has evolved since it was first performed on humans. This evolution mainly concerns the band’s position in relation to the gastric wall, which necessitated modifying the posterior dissection for band passage and placement. These technical changes have been aimed at reducing morbidity, especially the major complication, prolapse/slippage or pouch dilatation above the band. Based on personal experience and a review of the literature, the authors describe how the surgical technique has developed since the introduction of the LAP-BAND. The advantages of the LAP-BAND have contributed to its increasing use throughout the world. The authors believe that the approach represents a paradigm shift in bariatric surgery.

Experience with Lap-band System up to 7 years.

Morbid obesity occurs in 2-5% of the population of Western countries. Laparoscopic adjustable silicone gastric banding was designed to be a minimally invasive, adjustable and reversible procedure for the treatment of morbid obesity. The Lap-band System was evaluated retrospectively in a series of 543 patients. Data on preoperative aspects and postoperative outcome and weight loss patterns at up to 7 years follow-up (median follow-up 36 months) are presented. The most important late complication was total and irreversible food intolerance due to proximal pouch dilatation, which occurred in 24 patients (4.6%). 20 of these patients (3.8%) had had a proximal pouch calibration with 25 cc; 4 patients were calibrated with 15 cc. The mean BMI had fallen from 44 kg/m2 to 33.2 kg/m2 and was stable after a follow-up of up to 86 months (median 36 months). The Lap-band System is an effective procedure for achieving appreciable and stable weight loss at up to 7 years of follow-up (median 36 months). The minimally invasive approach was associated with a short hospital stay and a low rate of complications. Preoperative patient selection, detailed information and availability of the multidisciplinary team permitted us to achieve good longstanding results.

The long-term torsion effect of the adjustable Harada-Ito procedure

Purpose: The Harada-Ito procedure is a widely used technique in the treatment of excyclotorsion. While previous studies have demonstrated its initial success, long-term data have not been readily available. The purpose of this study is to describe the long-term torsion effect of the adjustable Harada-Ito procedure. Methods: All Harada-Ito procedures performed by 1 surgeon from 1982 to 1998 with at least 1 year of follow-up were reviewed. Torsion was evaluated using the double Maddox rods preoperatively, 1 day postoperatively, 2 months, 6 months, 1 year, 18 months, then annually thereafter. The effectiveness of the procedure was evaluated by comparing preoperative values to those at follow-up exams. The stability of the procedure was also evaluated by comparing torsion at 1 day and 2 months postoperatively to the torsion at subsequent exams. All comparisons were performed using the Student's t test. Results: Eighty Harada-Ito procedures were performed by 1 surgeon during this period. Nineteen patients had at least 1 year of follow-up (range, 1–7 years; mean, 2.0 years). Mean excyclotorsion values were 10.7° preoperatively, 1.0° at 1 day, 1.0° at 2 months, 3.4° at 6 months, 4.8° at 1 year, and 5.3° at 18 months. There was a significant improvement of excyclotorsion compared to preoperative torsion up to 12 months after surgery (P ≤.05). However, there was regression of the torsion effect from 2 months to 12 months after surgery (P =.02). After 12 months, there did not appear to be any further regression at 18 and 24 months postop (P =.79 and.84, respectively), although the number of patients with follow-up beyond 1 year was small (n = 3). Conclusions: The Harada-Ito procedure is an effective procedure to treat excyclotorsion. However, regression toward excyclotorsion occurs between 2 months to 12 months postoperatively. These results suggest that an initial overcorrection may aid in long-term success of this procedure. (J AAPOS 2002;6:141-4)

The Epidemic of Severe Obesity: The Value of Surgical Treatment

The Epidemic of Severe Obesity: The Value of Surgical Treatment

Cricothyroid subluxation: a new innovation for enhancing the voice with laryngoplastic phonosurgery.

Laryngoplastic phonosurgery has evolved to become a dominant treatment modality for paralytic dysphonia. Current surgical procedures have addressed primarily the position of the musculomembranous vocal fold and the arytenoid in the axial and vertical planes. However. dynamic range capabilities and vocal flexibility have been limited secondary to the flaccid, denervated vocal fold tissue. Therefore. a new procedure was conceived to enhance the acoustic vocal outcome from operations that reposition the vocal edge. Cricothyroid (CT) subluxation was designed as a technique to increase the distance between the cricoarytenoid joint and the insertion of the anterior commissure ligament. Cricothyroid subluxation was done without complication in 9 patients who underwent combined adduction arytenopexy and medialization laryngoplasty, and in 4 patients with medialization laryngoplasty alone. Postoperative stroboscopic assessment was done in all of the 13 patients, while complete analysis of vocal function was available in 10 of the 13 patients; this revealed improvement (as a group) on almost all objective measures over the preoperative state. All patients who underwent CT subluxation had a normal maximum frequency range (pitch variation of more than 2 octaves), as compared with 22% of a prior similar cohort of patients who did not undergo CT subluxation. All patients who underwent CT subluxation had normal glottal airflow and a normal noise-to-harmonics ratio. Cricothyroid subluxation is a relatively easily adjustable procedure that increases the length and viscoelastic tension of the denervated vocal fold. The modified biomechanical properties resulted in improved vocal outcome in all of our patients, which was most remarkable in terms of maximal range capabilities. Cricothyroid subluxation enhanced the postoperative voice of patients regardless of whether they required medialization laryngoplasty alone or whether they also required adduction arytenopexy.

A new fully adjustable articulator system and procedure

This article presents a simple and efficient articulator to help with the registration of maxillomandibular relationships, mounting casts, and subsequent perfection of the occlusal scheme for various types of prosthodontic restorations. The system (Individual Anatomo-Physiological system), which is composed of the articulator and recommended procedures, allows for registration of positions and trajectories of the mandible at the level of the patient’s occlusal plane. It is used to accurately transfer the records to the articulator. A luminous signal shows the correct centric occlusal relationship and vertical dimension, in both clinical and laboratory procedures. Interocclusal records are used for semiadjustment of the articulator for provisional restorations and stereographic records are used for full adjustment of the articulator for definitive treatment. (J Prosthet Dent 1998;80:376-86.)

Laparoscopic adjustable esophagogastric banding: a preliminary experience.

Laparoscopic adjustable gastric banding is an efficient surgical method in the treatment of morbid obesity. In order to reduce the number of complications, we have modified the technique to what we term 'laparoscopic adjustable esophagogastric banding'. Between December 1994 and July 1997, 126 laparoscopic adjustable banding procedures were carried out. Of these, 40 underwent a gastric banding operation (group 1), and 86 underwent an esophagogastric banding procedure (group 2). The percentage loss of excess body weight curve was less rapid in group 2 compared to group 1 due to a different strategy in band filling. Follow-up to date shows that no problems with the pouch or the stoma have arisen in the esophagogastric banding group. Laparoscopic adjustable esophagogastric banding is a simpler and safer procedure than laparoscopic adjustable gastric banding. It also works as a very efficient anti-reflux procedure, at least in the short term. It appears to be equally efficient as a weight-reducing operation as gastric banding. Further follow-up of the patients involved is necessary in order to evaluate the results in the longer term.

The adjustable globe: a technique for adjustable strabismus surgery.

Conventional adjustable strabismus surgery involves postoperative repositioning of individual muscles anchored to the sclera via adjustable sutures. Greaves has described anchoring opposing rectus muscles to one another, via sutures passing on either side of the limbus. With the muscles disinserted, the "freed" globe can be adjusted to the desired position within the resulting suture cradle. Friction of the sutures against the sclera holds the muscles in place until healing occurs. Using a cul-de-sac approach, we performed 23 horizontal and three vertical adjustable globe procedures, with median follow-up of 7 weeks. Four procedures were performed on nonhuman primates, monitored with iris fluorescein angiography. Esodeviations were well corrected, but exodeviations were often grossly undercorrected. Prolonged postoperative discomfort and photophobia were experienced. Possible evidence for mild anterior segment ischemia was noted. Concern about poor results with exodeviations, discomfort, and possible anterior segment ischemia led us to abandon this procedure.

Partial annular plication for atrioventricular valve regurgitation

Various annuloplasty techniques are used to correct tricuspid or mitral valve regurgitation. We performed a partial annular plication procedure, a modification of the annuloplasty introduced by Davila, in 23 consecutive patients with moderate to severe tricuspid regurgitation or moderate mitral regurgitation. A slender plastic tube was used to tighten snugly the suture during intraoperative saline flushing test for assessment of the valve competency. This technique enabled us to add one stitch or two for more plication before the suture was tied if necessary. During a mean follow-up period of 13.8 months postoperatively, 10 patients (43.5%) had no valve regurgitation, 12 patients (52.2%) had grade 1+ regurgitation, and 1 patient (4.3%) grade 2+ on color Doppler echocardiography. The regurgitation grade remained unchanged or improved after the initial postoperative study. Our surgical experience indicates that the adjustable procedure of partial annular plication is a simple, exact, and durable procedure in patients of all ages with moderate to severe functional atrioventricular regurgitation.

Modification of the Fasanella-Servat procedure: An adjustable ptosis procedure

The Fasanella-Servat procedure was initially used as a shortened, simplified operation for 2 to 3 mm of ptosis correction. Both then and now, this procedure is indicated in involutional ptosis and in patients with a good tear film function. Its main advantage over traditional ptosis surgery is that it is a truly adjustable procedure, allowing eyelid recontouring or lowering at 5 to 7 days after operating at the time of suture removal. In addition, no patient cooperation is required and surgery can be performed under general anesthesia or can be combined with more extensive surgical procedures that require deep sedation. The Fasanella-Servat procedure has been shown to use both a tarsectomy and advancement and reattachment of the levator aponeurosis. The ptosis correction achieved is independent of the amount of smooth muscle removed in the surgical specimen. During the postoperative interval, the surgeon has the advantage of waiting for edema to clear before readjustment and final contouring of the eyelid height is achieved at the first postoperative visit. This allows the surgeon to lower an eyelid if Hering's Law has created a contralateral ptosis or if the operated eyelid has less than a pleasing contour.

An efficient Eulerian‐Lagrangian Method for solving solute transport problems in steady and transient flow fields

A computationally efficient, yet relatively simple Eulerian‐Lagrangian method is proposed for solving the one‐dimensional convection‐dispersion solute transport equation assuming a steady or transient velocity field. The method uses a modified single‐step reverse particle tracking (MSRPT) technique to handle steep concentration fronts. The scheme utilizes two weighting factors to control the movement of particles during a backward tracking step. One weighting factor greater than unity is used in the upstream region of the convection front, while another weighting factor less than unity is taken in the downstream region. The two factors were related empirically to the grid Peclet and Courant numbers. The MSRPT technique is carried out only within the concentration plume at each time step. For transient flow fields, the weighting factors were determined using an automatically adjustable procedure based on mass balance errors. The MSRPT method maintains the advantages of the traditional single‐step reverse particle tracking (SRPT) procedure, i.e., producing efficient and oscillation‐free calculations, but circumvents numerical dispersion introduced by SRPT. A large number of tests against analytical solutions for one‐dimensional transport in uniform flow fields indicate that the proposed method can handle the entire range of Peclet numbers from zero to infinity. Numerical tests also show that the MSRPT method is a relatively accurate, efficient and mass‐conservative algorithm for solute transport in transient flow fields. The Courant number at present cannot exceed 1. The MSRPT approach was found especially useful for convection‐dominated problems; in fact, an exact numerical solution may be obtained with MSRPT for pure convection.

Adjustable suture strabismus surgery for acquired vertical deviations.

Forty-seven patients undergoing 51 adjustable suture strabismus procedures for acquired vertical deviations were evaluated for preoperative and adjustment factors which might influence the postoperative alignment. The type of deviation, surgical procedure, previous surgery, immediate postadjustment alignment, and immediate postadjustment versions were assessed. Oblique muscle surgery in addition to an adjustable vertical rectus muscle significantly decreased the success rate (p = .0303). Other less important factors were a previous history of strabismus surgery and a moderate limitation of versions following the adjustment. A slight over- or undercorrection after adjustment did not affect the success.

Long-Term Strabismus Complications Following Retinal Detachment Surgery

Thirty-three consecutive patients with persistent strabismus following retinal detachment surgery were studied retrospectively. A large number of vertical and torsional problems were seen. Various restrictive abnormalities were identified during strabismus surgery. These included superior oblique tendon displacement anteriorly, leash and reverse leash types of restrictions, myoscleral adhesions posterior to the exoplants, and stretching of the muscles induced by large underlying exoplants. The results following strabismus surgery were analyzed. Eighty percent of the patients were able to achieve single binocular vision in the primary field of gaze, with a low incidence of complications. The adjustable suture procedure was thought to be helpful.

Generalization of body size distortion

Thirty-four asymptomatic, normal weight college females were assessed for levels of body size overestimation for self-relevant body areas and corresponding sites on a normal-sized department store mannequin. An adjustable light beam procedure was used for all measures. Minimal differences between black and white subjects eventuated. A consistent pattern emerged indicating greater overestimation for self than mannequin; however, this was not true for all body sites assessed. A greater number of significant correlations among self-estimates and mannequin scores were found than significant relationships between self and mannequin distortion quotients. The results are discussed with regard to the generalizability of body size overestimation.

A Combined Surgical Approach to Bilateral Superior Oblique Palsy

In two cases of bilateral superior oblique palsy the vertical component of the deviation was more prominent in one eye and the excyclotorsion more prominent in the fellow eye. A tuck of the superior oblique was performed on one eye and an adjustable Harada-Ito procedure on the fellow eye. This combined approach was used to reduce both the torsional and vertical components in these patients with complicated bilateral superior oblique palsies while effecting a more exact resolution of the torsional component.

Current Techniques of Adjustable Strabismus Surgery

Adjustable strabismus surgical procedures provide the opportunity to reposition a surgically altered muscle position, which is often necessary for nonaverage cases of strabismus correction. The usual surgical procedure is extended into the postoperative period (same hospitalization) so that the surgeon may satisfactorily monitor the total end result (by cover test and rotations) at the time of adjustment. Adjustable techniques should be considered whenever a desired goal is unlikely to be reached in one surgical session. Recent technical improvements allow satisfactory globe position control during the adjustment stage for ease of recession or resection adjustment. Globe stabilization is attained during surgery and the postoperative adjustment by means of a scleral loop handle, placed near the corneoscleral limbus. Millimeters of adjustment are easily estimated by means of a sliding suture knot technique.

An Adjustable Transposition Procedure for Abduction Deficiencies

We used an adjustable transposition procedure in two cases of horizontal abduction deficiency (one of lateral rectus palsy and one of Duane syndrome with marked co-contraction). Primary position balanced alignment and maximum balanced rotations were obtained without inducing vertical deviation as the result of the transposition. The vertical force vectors were neutralized by the self-adjusting nature of the vertical rectus union. The procedure allowed for both intraoperative and postoperative adjustment of the result.

Adjustable Rectus Muscle Recession Surgery

Fifty-six patients underwent an adjustable rectus muscle recession procedure. This procedure permits the surgeon to enhance or diminish the amount of muscle recession on the evening after surgery or the first postoperative day if cover-testing indicates an inappropriate amount of undercorrection or overcorrection. The adjustable rectus muscle recession technique seems to be a practical and effective means to change the strabismic deviation postoperatively. The procedure requires patient cooperation and is most suitable for patients age 15 years and older. The procedure has been effective in altering the angle of deviation, and this alteration has been stable during the follow-up period in most cases. In this initial series, the reoperation rate was low, postoperative alignment was excellent, and complications were minimal.