Combined Surgery Group Research Articles

Angiographic Results of Indirect and Combined Bypass Surgery for Adult Moyamoya Disease

ObjectiveThe aim of this study was to compare the efficacy of indirect and combined bypass surgery for treatment of adult moyamoya disease (MMD). The definition of combined bypass surgery is a combination of superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis and indirect anastomosis. Development of collateral circulation after surgery was investigated.MethodsForty three patients (58 hemispheres) with MMD were followed by cerebral angiography for at least six months after surgery, between May 2002 and July 2011. Indirect and combined revascularization surgeries were performed in 33 and 25 cases, respectively. Good outcome was defined as more than group B, in accordance with the method suggested by Matsushima.ResultsDevelopment of collateral circulation was not affected by sex (p = 0.493), clinical features (p = 0.206), or Suzuki stage (p = 0.428). Based on postoperative cerebral angiography, the combined bypass surgery group showed a better angiographic outcome, than the encephaloduroarteriomyosynangiosis (EDAMS) group (p = 0.100, odds ratio [OR] 4.107, 95% confidence interval [CI] 0.700 - 24.096). The combined bypass group showed a better response than the encephaloduroarteriogaleosynangiosis (EDAGS) group (p = 0.088, OR 4.600, 95% CI 0.721 - 29.332). Similar responses were observed for EDAGS and EDAMS (p = 0.886, OR 1.120, 95% CI 0.239 - 5.251). The combined bypass group showed a better response than the indirect group (p = 0.064, OR 4.313, 95% CI 0.840 - 22.130).ConclusionResults of this study demonstrate that combined bypass results in better revascularization on angiographic evaluation in adult MMD. Therefore, among surgical procedures, combined bypass is a choice that can be recommended.

Combined cataract and trabeculectomy surgery in eyes with pseudoexfoliation glaucoma

To assess the short- and long-term effect of uneventful phacoemulsification, posterior chamber intraocular lens (IOL) implantation, and trabeculectomy on intraocular pressure (IOP) and glaucoma medication requirements in eyes with pseudoexfoliation glaucoma (PXG) and compare the results with those in eyes that had uneventful phacoemulsification only (reported in a previous study of the same cohort of pseudoexfoliation eyes). Private practice, Boston, Massachusetts, USA. Comparative case series. A retrospective analysis was performed of consecutive PXG eyes that had uneventful combined phacoemulsification and trabeculectomy by the same surgeon. The change in IOP, glaucoma medication requirements, and logMAR corrected distance visual acuity was compared between the combined surgery group and the phaco-alone group. The combined-surgery group (n = 138) had statistically significant reduced mean IOP and glaucoma medication requirements through 10 years postoperatively (P<.018). The change in IOP and glaucoma medication requirements was greater in the combined-surgery group than in the phaco-alone group (n = 240); this was statistically significant up to 7 years postoperatively (P<.022). The reduction in mean postoperative IOP was greater in eyes with a higher mean preoperative IOP. In the combined-surgery group, 13.8% of eyes required subsequent laser trabeculoplasty, glaucoma surgery, or both. Uneventful phacoemulsification, IOL implantation, and trabeculectomy resulted in significant long-term reduction in IOP and glaucoma medication requirements in eyes with PXG. Combined procedures resulted in greater and more longstanding reductions in IOP and glaucoma medication requirements and fewer 1-day postoperative IOP spikes than phacoemulsification alone. No author has a financial or proprietary interest in any material or method mentioned.

Patients with advanced glaucoma with controlled intraocular pressure and visually significant cataract: phacoemulcification vs combined surgery

AbstractPurpose cataract surgery alone may have a beneficial effect in glaucoma patients by mildly lowering the intraocular pressure but loss of intraocular pressure (IOP) control may occur after cataract operation. It has also been suggested that patients presenting with more advanced glaucoma may have better outcomes with surgery than medical treatment. The purpose of the study is to investigate the postoperative results of two surgical alternatives: phaco only versus combined phaco trab operation in eyes with advanced glaucoma and controlled IOP.Methods Prospective study of 78 patients with advanced open angle glaucoma (MD≥12 dB) with IOP≤21mmHg on topical medication and visually significant cataract (VA ranging from Hand Movements to 4/10). All patients were randomized to have either combined surgery (phaco‐trab, two‐sites, using adjustable sutures) (Group A, 39 eyes) or phaco only ( clear cornea temporal approach) (Group B, 39 eyes). Follow up for 6 months. VA, IOP and VF were measured regularly with appropriate IOP control. Postoperative complications were recorded.Results Phaco group showed faster visual recovery, higher peak IOP, greater IOP fluctuations and less MD difference than phaco_trab group, with the latter performing worse. Final VA didn't differ significantly between groups. Major complications: 9 choroidal detachments and 1 hyphema in Group A.Conclusion for the first 6mo postoperatibvely higher IOPs in phaco only patients do not seem to worsen glaucoma lesions given strict IOP control. Even more, phaco_only eyes show faster visual improvement and need less prolonged intensive postoperative monitoring than phaco_trab eyes.

Macular Hole Surgery and Cataract Extraction: Combined vs Consecutive Surgery

To compare the functional and the anatomic outcomes of a combined surgery and consecutive surgery for macular hole and cataract extraction. Multicenter, retrospective, comparative case series. One hundred twenty patients (120 eyes) with an idiopathic macular hole and cataract were operated on in 1 or 2 sessions in 2 academic centers, Dijon University Hospital and Nancy University Hospital. Combined surgery (n = 64) and consecutive surgery (n = 56) were performed between 2006 and 2007. All patients underwent pars plana vitrectomy with internal limiting membrane peeling and gas tamponade. Cataract extraction was performed with phacoemulsification followed by a posterior chamber intraocular lens implantation. The main outcome measures were near and far visual acuity at 6 and 12 months, and the rate of closure of macular hole evaluated with optical coherence tomography. After a 12-month follow-up, the postoperative best-corrected visual acuities significantly improved in both the combined and the consecutive surgery groups (near and far vision in both groups, P < .0001). However the improvement of far visual acuity was not significant in the consecutive surgery group at 6 months (P = .06) while such an improvement was observed in the combined surgery group (P < .0001). The rates of closure, 100% and 96% in the combined and the consecutive groups respectively, and the complications did not differ significantly between groups. Both combined and consecutive surgeries are safe and effective methods to treat macular hole and cataract with equivalent functional and anatomic results in both procedures. However, combined surgery shortened the delay for visual recovery.

Combined Carotid and Cardiac Surgery: Improving the Results

Aim of this study was to analyze our experience in the last 5 years of combined carotid and cardiac surgery. During a 5-year period (January 2002-December 2006), 111 patients underwent combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) (group 1), while 1,446 patients underwent isolated CEA (group 2). Perioperative outcomes in the two groups were compared using chi(2) and Fisher's exact tests to analyze neurological deficits, cardiac events, and death at 30 days. Results during follow-up were analyzed using Kaplan-Meier survival curves, and both groups were compared using the log-rank test. Immediate postoperative neurological deficits occurred more frequently in group 1 patients (2.5 vs. 0.4%, p = 0.002), with a higher incidence of transient ischemic attacks in group 1; however, there was no difference in the incidence of stroke (1% group 1 vs. 0.6% group 2, p = n.s.). Mortality rate was increased in the combined surgery group (3.5 vs. 0.5%, p < 0.001). Combined stroke/myocardial infarction/death rate at 30 days was 6.3% in group 1 compared with 1.4% in group 2, p = 0.001. Perioperative stroke/myocardial infarction/death rate was much improved in the 55% (61/111) of patients undergoing CABG off-pump (3.3 vs. 10%, p = 0.001). Mean follow-up was 18.7 months (range, 1-60). Survival at 24 months was significantly higher in patients of group 2 compared with group 1 (99.4 vs. 91.3% respectively, p < 0.001). At 24 months, there was no significant difference between the two groups in the risk of developing ipsilateral or contralateral neurologic events (3.1% group 1 vs. 1.7% group 2). In our experience, combined CEA and cardiac surgery carries a higher risk of perioperative mortality than patients undergoing isolated CEA. Whenever possible, CEA combined with off-pump CABG seems to be the therapeutic strategy of choice.

Corneal endothelial cell loss after trabeculectomy or after phacoemulsification, IOL implantation and trabeculectomy in 1 or 2 steps

To assess endothelial cell damage after glaucoma surgery and combined glaucoma and cataract surgery in one or two steps using confocal biomicroscopy. This is an observational retrospective study. Eighty eyes from 62 patients between 60 and 83 years of age were studied. Eyes fell into a control group (n = 21) and three experimental groups, in which trabeculectomy (group 1; n = 21) or trabeculectomy and phacoemulsification and intraocular lens implantation had been performed, in one (group 2; n = 21) or two (group 3; n = 17) steps between 6 months and 5 years before. In the control group, mean corneal endothelial cell density (+/-SD) was 2,619 +/- 319 cells/mm(2), whereas in the experimental groups 1, 2 and 3 it was 2,447 +/- 425, 1,968 +/- 342 and 1,551 +/- 323 cells/mm(2) respectively. Cell densities found in the combined surgery groups were significantly smaller than the densities of the control or trabeculectomy groups. The variation coefficient of the endothelial cell area (+/-SD) was 41.19 +/- 7.46% in the control group and 38.9 +/- 6.02, 42.37 +/- 9.53 and 45.71 +/- 11.96% in groups 1, 2 and 3 respectively, differences that were not statistically significant. The percentage of hexagonality (+/-SD) was 51.10 +/- 8.41% in the control group and 51.4 +/- 6.88, 45.13 +/- 8.40 and 42.37 +/- 9.53% in the experimental groups 1, 2 and 3 respectively, but again there were no significant differences between them. Combined trabeculectomy, phacoemulsification and intraocular lens implantation causes more endothelial cell damage than trabeculectomy alone, and the two-step combined procedure causes more damage to the endothelium than the one-step combined procedure.

Surgically induced astigmatism after 23-gauge transconjunctival sutureless vitrectomy

To evaluate surgically induced astigmatism (SIA) after 23-gauge transconjunctival sutureless vitrectomy (23GTSV). We studied 56 patients (56 eyes) who underwent 23GTSV between January 2006 and December 2007 and who underwent preoperative and 1- and 3-4-months postoperative corneal topography. Fifteen of the 56 patients underwent combined 23GTSV and cataract surgery. SIA was evaluated with Naeser's polar method using the simulated keratometric values obtained with corneal topography. Preoperative and postoperative KP and DeltaKP values were compared in the 23GTSV only group and the combined 23GTSV and cataract surgery group. There were no significant serial changes between the preoperative and postoperative Sim K astigmatism or KP values in the 23GTSV only group. In the 23GTSV only group, the DeltaKP (90) was negative (-0.10+/-0.78) at 1 month postoperatively, but it became positive (0.13+/-0.85) at 3-4 months postoperatively. The DeltaKP (135) showed serially decreasing negative values, -0.02+/-0.80 at 1 month postoperatively and -0.08+/-0.60 at 3-4 months postoperatively. In the combined cataract surgery group, the 1- and 3-4-month postoperative DeltaKP (135) values were -0.64+/-0.50 and -0.71+/-0.48, respectively, which represented a significant decrease compared with the 23GTSV only group (P<0.001, Mann-Whitney U-test). Although statistically insignificant, the DeltaKP (135) value was more negative in the sclerotomy-sutured group (n=6) than the sclerotomy non-sutured group (n=35) at 1 month postoperatively (-0.67+/-1.19 vs 0.09+/-0.67, P=0.110, Mann-Whitney U-test). The 23GTSV does not induce significant SIA in the early postoperative period.

Comparison of Posterior Capsular Opacification between a Combined Procedure and a Sequential Procedure of Pars Plana Vitrectomy and Cataract Surgery

Purpose: To compare posterior capsular opacification (PCO) between a combined procedure and a sequential procedure of pars plana vitrectomy (PPV) and cataract surgery (CS). Methods: The medical records of 89 eyes of 85 patients who underwent PPV and CS were retrospectively reviewed. There were 56 eyes of 52 patients with a combined PPV and CS (the combined surgery group), and 33 eyes of 33 patients with CS in a previously vitrectomized eye (the sequential surgery group). The control group was comprised of 130 eyes of 102 patients who underwent CS alone. All patients were followed up for at least 1 year after CS. The major outcome measures were the PCO rate and the interval between CS and PCO formation. There were no significant differences in age and the incidence of diabetes among the 3 groups. Results: The PCO rate checked at 1 year after CS was 12.5% (7/56) in the combined surgery group, 24.2% (8/33) in the sequential surgery group, and 4.6% (6/130) in the control group. The differences in the PCO rate between the subgroups as well as among the 3 groups were statistically significant (p < 0.05). There were no significant differences in the interval between CS and PCO formation among the 3 groups. Conclusion: This study demonstrates that the PCO rate may be lower in patients who have a combined procedure of PPV and CS than in those who have a sequential procedure.

Long term follow-up of the comparison between combined surgery and sequential surgery in treating proliferative diabetic retinopathy

Objective To observe the therapeutic efficacy and postoperative complications of combined surgery and sequential surgery in treating proliferative diabetic retinopathy (PDR) and cataract.Methods The cilinical data of 59 patients (66 eyes) with PDR were retrospectively analyzed.The patients were divided into combined-surgery group and sequential-surgery group.Combined surgery was performed on patients with obvious lens opacity which was an obstacle to the ocular fundus surgery,while sequential surgery was performed on the patients with transparent lens or lens with light opacity on which ocular fundus surgery could be performed.Lens excision in cataractopoiesis could only be performed when the state of ocular fundus was stable and cataractopoiesis was the main cause of vision damage.A total of 28 patients (32 eyes) in combined-surgery group underwent vitrectomy combined with phacoemulsification and IOL implantation;31 patients (34 eyes) in sequential-surgery group underwent vitrectomy,lens excision and IOL implantation.Corrected visual acuity (BCVA) and complications were observed.The mean follow-up period was (25±8.5) months.The measurement data were analyzed with t test and enumeration data with 2 test.Results In combined-surgery group,visual acuity improvement was achieved in 27 eyes (84.4%),remained unchanged in 2 eyes (6.3%) and decreased in 3 eyes (9.4 %).In sequential-surgery group,visual acuity improved in 26 eyes (76.5%),remained unchanged in 2 eyes(5.8%)and decreased in 6 eyes (17.7%.).However,anterior chamber fibrin exudation occurred in 4 eyes in the combined-surgery group and no eyes in the sequential-surgery group;compared with each other,the difference is statistically significant (χ2=4.524,P=0.033).Conclusion Combined surgery and sequential surgery are all safe and effective on treating PDR and postoperative complications have no obvious correlation with the surgery procedure. Key words: Diabetic Retinopathy/surgery; Vitrectomy; Phacoemulsification

The influence of seasonal variation on cardiac surgery: A time-related clinical outcome predictor

The effect of seasonal variation on cardiac surgery outcomes is unknown. We investigated the effect of season on risk-adjusted hospital mortality and length of stay. Prospectively collected data from cardiac operations at one center between April 1996 and March 2006 were analyzed. Seasonal variation in outcomes was studied by using multiple regression models that included EuroSCORE and year of operation to adjust for risk profile and changes over time. Analysis was performed for 2 separate surgical groups: patients having coronary artery bypass grafting only and patients having other cardiac procedures with or without coronary artery bypass grafting. There were 16,290 patients who had a first record of cardiac surgery in the study period between April 1, 1996, and March 31, 2006, with 10,263 patients having coronary artery bypass grafting only and 6027 patients having another procedure with or without coronary artery bypass grafting. There were increased odds of hospital mortality in patients having operations in winter compared with the average across all seasons for both surgical groups, although this was only significant in the coronary artery bypass grafting-only group (odds ratio, 1.29; 95% confidence interval, 1.01-1.63; P = .04). There were decreased odds of death in the coronary artery bypass grafting-only group in summer (odds ratio, 0.76; 95% confidence interval, 0.60-0.96; P = .02). Intensive care unit stay was 4% (95% confidence interval, 1%-6%) longer in the coronary artery bypass grafting-only group in winter and 3% (95% confidence interval, 1%-5%) shorter in summer than the average stay (P = .003 and .006, respectively). There were no differences in intensive care unit stay in the combined surgery group by season and no differences in total length of stay for either group (coronary artery bypass grafting only and coronary artery bypass grafting with other cardiac procedures). Cardiac surgery outcomes are influenced by the time of year. Hospital mortality and intensive care unit stay after coronary artery bypass grafting were increased during the winter season compared with the rest of the year.

Improved survival in patients with malignant pleural mesothelioma since 2003

19022 Background: In our chest hospital patients with malignant pleural mesothelioma (MPM) were treated since decades. We compare patients survival before and after the introduction of a new chemotherapy regimen (platinum/pemetrexed) 2003. Methods: Between 1990 and December 2007 we diagnosed and treated 338 patients with MPM, 278 males and 60 females. All patients were retrospectively analyzed. Standard treatment in our institution for patients with good performance status is palliative surgery with pleurectomy and decortication, followed by chemotherapy. Only few patients had extra pleural pleuropneumonectomy (EPP), followed by chemotherapy. Our therapeutic strategy has not changed in the last years. We divided our patients in 2 treatment groups: those with diagnosis before 2003 (group I: 250 patients) or a diagnosis of MPM since 2003 (group II: 88 patients). Since 2003 all patients were treated with the platinum/pemetrexed combination. Results: Median survival (Kaplan-Meier-method) of all patients, diagnosed between 1990 and 2007 was 462 days with a 1- year-survival of 60% and a 2-year-survial of 37%. Median survival of group I (250 patients, 16% censored) was 352 days, compared to 652 days in group II (72% censored) and has nearly doubled. 1-year surval increased from 58% (group I) to 90% (group II), as well as the 2-year- survival, which increased from 28% (group I) to 48% (group II). Median survival of the patients with combined surgery and chemotherapy group I (104 pat., 25% censored) increased from 522 days to 1,046 days in group II (46 pat., 82% censored). In the patient group treated only with chemotherapy, 1-year survival improved from 60% to 85% and the 2-year survival from 20% to 40%. Conclusions: The introduction of an effective chemotherapy regimen 2003 with platinum/pemetrexed prolonged survival in patients with malignant pleural mesothelioma. This survival benefit was seen in multimodal treatment regiments as well in patients under chemotherapy alone. No significant financial relationships to disclose.

Simultaneous Carotid Endarterectomy and Coronary Artery Bypass Grafting: Results in Specific Patient Groups

We examined the safety of performing synchronous carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) in specific groups of patients with coexistent cerebral and coronary vascular disease. Between 1981 and 2003, 8,277 patients who underwent CABG in our institution had noninvasive screening for carotid disease. Two hundred seventy-seven (3.34%) patients were found to have severe (>70%) carotid stenosis. This patient population was divided into three subgroups: group A had unilateral carotid disease (n = 200), group B had bilateral carotid disease (n = 55), and group C had contralateral carotid occlusion (n = 22). In 29 patients (10.4%), the carotid disease was symptomatic. A simultaneous CABG and CEA was performed in all three subgroups. Patients in group B underwent initially repair of the most dominant lesion, soon followed by contralateral CEA. Patients who underwent only CABG (n = 8,000) served as controls. Overall combined hospital mortality regardless of etiology for the combined group was 3.61% vs. 1.7% for the patients who had CABG only (P > 0.1). The stroke and/or myocardial infarction-associated mortality for the simultaneous CEA-CABG group was 2.52%. There were six deaths in group A (3%), two in group B (3.6%), and two in group C (9.09%). Early stroke complicated the course of four (2%) patients in group A, one (1.8%) patient in group B, and three (13.64%) patients in group C compared to a stroke rate of 1.28% in controls. Overall stroke rate in the combined group was 2.8%. History of previous stroke and age 70-80 were the most important predictors of postoperative stroke and death. In the combined surgery group, the postoperative myocardial infarction rate was 0.72% vs. 0.58% in the control group. The mean length of hospital stay was 9 days for patients who had the combined procedure vs. 8.1 days for patients who had CABG only. Use of the combined procedure for patients with concomitant carotid and coronary artery disease was justified in the patients under study.

Vitrectomy combined with phacoemulsification and intraocular lens implantation for treatment of proliferative diabetic retinopathy

To determine clinical outcomes of vitrectomy and silicone oil tamponade combined with phacoemulsification and foldable intraocular lens (IOL) implantation for the treatment of severe proliferative diabetic retinopathy (PDR). Fifty-three patients (57 eyes) with proliferative diabetic retinopathy were included in this study. All patients had tractional or tractional-rhegmatogenous retinal detachment. These patients were divided into combined surgery group and vitrectomy group. Thirty-three patients (33 eyes) of combined surgery group underwent vitreoretinal surgery and silicone oil tamponade combined with phacoemulsification and foldable intraocular implantation. Twenty patients (24 eyes) of vitrectomy group underwent vitreoretinal surgery and silicone oil tamponade only. The postoperative rates of retinal reattachment and complications were analyzed. Rates of retinal reattachment in combined surgery group was 87.9% vs. 83.3% for vitrectomy groups. The difference in rates of retinal reattachment was not statistically significant between these 2 groups (P > 0.05). Rates of visual acuity better than 0.1 in combined surgery group was 60.6% vs. 33.3% in vitrectomy group 6 month after operation. The difference in rates of postoperative iris neovascularization was not statistically significant between these 2 groups (P > 0.05). Combined vitreoretinal surgery and phacoemulsification with intraocular lens implantation is safe and effective in treating severe proliferative diabetic retinopathy. Combined surgery may prevent a second operation for post vitrectomy cataract, allowing earlier visual rehabilitation.

Determination of the threshold of cardiac troponin I associated with an adverse postoperative outcome after cardiac surgery: a comparative study between coronary artery bypass graft, valve surgery, and combined cardiac surgery

IntroductionThe objective of the present study was to compare postoperative cardiac troponin I (cTnI) release and the thresholds of cTnI that predict adverse outcome after elective coronary artery bypass graft (CABG), after valve surgery, and after combined cardiac surgery.MethodsSix hundred and seventy-five adult patients undergoing conventional cardiac surgery with cardiopulmonary bypass were retrospectively analyzed. Patients in the CABG (n = 225) and valve surgery groups (n = 225) were selected after matching (age, sex) with those in the combined surgery group (n = 225). cTnI was measured preoperatively and 24 hours after the end of surgery. The main endpoint was a severe postoperative cardiac event (sustained ventricular arrhythmias requiring treatment, need for inotropic support or intraaortic balloon pump for at least 24 hours, postoperative myocardial infarction) and/or death. Data are presented as the median and the odds ratio (95% confidence interval).ResultsPostoperative cTnI levels were significantly different among the three groups (combined surgery, 11.0 (9.5–13.1) ng/ml versus CABG, 5.2 (4.7–5.7) ng/ml and valve surgery, 7.8 (7.6–8.0) ng/ml; P < 0.05). The thresholds of cTnI predicting severe cardiac event and/or death were also significantly different among the three groups (combined surgery, 11.8 (11.5–14.8) ng/ml versus CABG, 7.8 (6.7–8.8) ng/ml and valve surgery, 9.3 (8.0–14.0) ng/ml; P < 0.05). An elevated cTnI above the threshold in each group was significantly associated with a severe cardiac event and/or death (odds ratio, 4.33 (2.82–6.64)).ConclusionThe magnitude of postoperative cTnI release is related to the type of cardiac surgical procedure. Different thresholds of cTnI must be considered according to the procedure type to predict early an adverse postoperative outcome.

Combined or two sessions operation for complex retinal detachment accompanied with cataract

目的 回顾分析联合或分次行玻璃体切除与晶状体超声乳化吸出术治疗复杂性视网膜脱离合并白内障患者的资料,探讨影响手术结果的因素.方法 70例根据手术方式分为A组:白内障摘出+人工晶状体(IOL)植入+玻璃体切除;B组:白内障摘出(不植入IOL)+玻璃体切除;C组:分两步进行,白内障摘出+IOL植入,之后玻璃体切除;D组:分两步进行,白内障摘出(不植入IOL),之后玻璃体切除.术后随访6～40月.监测术后最佳矫正视力并比较不同术式后的并发症.结果 术后随访6月以上,所有组术后视力与术前相近或提高.多因素逻辑回归提示术后视力与手术前视力,眼底其他病变和视网膜脱离的时间、复杂程度相关.未植入IOL组后发障发生率较植入IOL组高.结论 合理选择玻璃体切除联合晶状体超声乳化吸出术可提高复杂性视网膜脱离合并白内障的手术后视力.黄斑孔视网膜脱离并非IOL植入的禁忌症。

Combined Anterior Plus Posterior Stabilization Versus Posterior Short-Segment Instrumentation and Fusion for Mid-Lumbar (L2–L4) Burst Fractures

Prospective randomized study. OBJECTIVES.: To compare the results of the combined anterior-posterior surgery (Group A) with posterior "short-segment" transpedicular fixation (SSTF) (Group B) in mid-lumbar burst fractures. There are no comparative randomized clinical studies on the outcome following operative treatment of mid-lumbar fractures. Forty consecutive patients with L2-L4 fresh single A3-type/AO burst fractures and load sharing score up to 6 were randomly selected to underwent either combined one-stage anterior stabilization with mesh cage and SSTF (Group A) or solely SSTF with intermediate screws in the fractured vertebra (Group B). Kyphotic Gardner angle, anterior and posterior vertebral body height (PVBHr, AVBHr), spinal canal encroachment (SCE), SF-36, VAS, and Frankel classification were used. The follow-up observation averaged 46 and 48 months for Group A and B, respectively. Operative time, blood loss, and hospital stay were significant more in Group A. More surgical complications were observed in the Group A. After surgery, VAS was reduced to 4.3 and 3.6 for Group A and Group B, respectively. The SF-36 domains Role physical and Bodily pain improved significantly only in Group B (P = 0.05) and (P = 0.06), respectively. Correction of AVBHr, PVBHr, and spinal canal clearance was similar in both groups. Spinal canal clearance did not differ between the two groups, but it was continuous until the last evaluation in Group B. The final Gardner angle loss of correction averaged 2 degrees and 5 degrees for Group A and Group B, respectively. The posttraumatic Gardner deformity did not significantly improve by SSTF at the final evaluation in the spines of Group B. Gardner angle correlated significantly with SCE in Group B and Group A in all three periods and in the last evaluation, respectively. Frankel grade did not correlate with loss of correction of AVBHr and PVBHr in Group A, while it significantly correlated with loss of PVBHr correction and SCE in the patients of Group B. There was no neurologic deterioration after surgery in any patient. VAS and SF-36 scores did not significantly correlate with the loss of kyphotic angle correction and AVBHr, PVBHr at the final observation in any patient of both groups. SSTF offered similar significant short-term correction of posttraumatic deformities associated with mid-lumbar A3-burst fractures, but better clinical results as compared to combined surgery. However, SSTF did not significantly maintain the after surgery achieved correction of local posttraumatic kyphosis at the final evaluation. Thus, SSTF is not recommended for operative stabilization of fractures with this severity.

Management of Retinal Detachment When No Break Is Found

To review the results of 2 different surgical approaches in the management of primary rhegmatogenous retinal detachments (RDs) with undetected retinal breaks. Retrospective, consecutive, interventional case series. Medical records of 44 patients with uncomplicated macula-involving primary rhegmatogenous-appearing RDs, but without retinal breaks detected preoperatively or intraoperatively, were reviewed. All study patients were operated by the same surgeon between 1989 and 2004 using 2 approaches: 26 (59%) patients underwent a scleral buckling procedure (SBP) with or without subretinal fluid drainage, whereas 18 (41%) patients underwent scleral buckling combined with pars plana vitrectomy (PPV), fluid-gas exchange, and broad application of endolaser. Single operation and final postoperative anatomic success, and 2-month postoperative and final best-corrected visual acuity (VA) (negative logarithm of the minimum angle of resolution [logMAR]). Mean preoperative VAs were 1.73 logMAR units (median, 1.60; range, 0.48-2.60) in the combined surgery group and 1.52 logMAR units (median, 1.30; range, 0.30-2.60) in the scleral buckling group. Neither preoperative (P = 0.33), 2-month postoperative (P = 0.53), best-corrected (P = 0.98), nor final (P = 0.46) mean VA showed any statistically significant differences between the 2 treatment groups. A single operation reattachment rate of 72% (13/18 cases) was achieved in the combined surgery group, compared with 61.5% (16/26 cases) in the scleral buckling group (P = 0.17, log rank test). Immediate anatomic success rates were 89% after combined treatment and 38.5% after scleral buckling alone (P = 0.002). At the final visit, the retina was attached in 15 (83.3%) patients who received the combined treatment and in 22 (84.6%) patients who underwent scleral buckling (P = 0.900). Intraoperative subretinal hemorrhage occurred in 1 (5.6%) patient from the combined surgery group and in 2 (7.7%) patients from the scleral buckling group. Retinal incarceration in the drainage sclerotomy occurred in 1 (3.8%) case during the SBP. Proliferative vitreoretinopathy sufficient to require reoperation developed in 1 (5.6%) eye of the combined surgery group and in 3 (11.5%) eyes of the scleral buckling group. Scleral buckling is as effective in the management of uncomplicated rhegmatogenous RDs with undetected breaks as is surgery combining scleral buckling and PPV.

Is Intraocular Pressure in the Early Postoperative Period Predictive of Antimetabolite-Augmented Filtration Surgery Success?

To determine whether intraocular pressure (IOP) in the early postoperative period after trabeculectomy or combined phacoemulsification-trabeculectomy, augmented with antimetabolite, correlates with IOP at one year in surgeries considered to be successful at that time point. Retrospective case series. A chart review of antimetabolite-augmented surgical procedures done by DJG and JBS between January 1994 and November 2000 identified 82 primary or secondary trabeculectomies and 53 combined phacoemulsification-trabeculectomies with at least one year of follow-up. The success rate for each surgical subgroup was calculated and IOP on postoperative days (POD +/- SD) 1, 7 (+/-2), 30 (+/-5), 90 (+/-10), and 180 (+/-20) was correlated with IOP at one year (POY 1, between month 12 and 15) using linear regression. IOP at each time point was compared among eyes that achieved success at one year with and without the use of IOP-lowering agents. Of the 82 eyes having undergone antimetabolite-augmented trabeculectomies and the 53 eyes having undergone combined surgeries with at least one year of follow-up, the surgical success rates at POY 1 were 87.8% (72 of 82 eyes) and 92.5% (49 of 53 eyes). Of these, 42 eyes (58.3%) from 39 patients in the trabeculectomy group and 27 eyes (55.1%) from 24 patients in the combined surgery group did not require glaucoma medications at one year postsurgically, and were considered complete surgical successes. Mean preoperative IOP mm Hg +/- SD was 26.0 +/- 8.5 for the trabeculectomy group and 18.2 +/- 4.5 for the phaco-trabeculectomy group. Postoperative IOP at POD 1, POD 7, POD 30, POD 90, POD 180, and POY 1 respectively for the eyes undergoing trabeculectomy were 13.9 +/- 10.4, 9.5 +/- 6.2, 12.0 +/- 5.5, 12.0 +/- 5.2, 12.8 +/- 5.9, and 12.1 +/- 4.3, and for the combined surgery group were 20.8 +/- 12.5, 9.7 +/- 5.7, 12.2 +/- 5.4, 11.1 +/- 3.4, 11.6 +/- 4.6, and 10.3 +/- 4.3. Intraocular pressure on postoperative day one correlated poorly with intraocular pressure at POY 1 for the trabeculectomy group (R2 = 0.0788), and not at all for the combined procedures group (R2 = 0.018). The correlation was slightly better for intraocular pressure at postoperative day 90 for the trabeculectomy group (R2 = 0.546), and at postoperative day 180 for the combined group (R2 = 0.37), but still rather low. Eyes requiring glaucoma medication use at POY 1 in the trabeculectomy group had higher (P < 0.009) intraocular pressure at POD 30 and at all subsequent visits than eyes not requiring these medications. Eyes requiring glaucoma medication use at POY 1 in the phaco-trabeculectomy group had higher (P < 0.0025) intraocular pressure at POD 30, POD 180, and POY 1 than eyes not requiring these medications. Intraocular pressure in the early postoperative period correlates very poorly with intraocular pressure one year after successful antimetabolite-augmented trabeculectomy or combined cataract extraction and trabeculectomy. Starting one month after glaucoma surgery, intraocular pressure is substantially lower in eyes that will ultimately not require the use of ocular hypotensive agents to achieve clinical success one year postoperatively.

Combined Cytoreductive Surgery and Early Postoperative Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis of Gastric Cancer.

Peritoneal seeding is the most common type of metastasis or recurrence and one of the poor prognostic factors in gastric cancer. Moreover, there are as yet no effective treatment modalities available. Recently some research groups suggested the benefit of combined cytoreductive surgery and intraperitoneal chemotherapy, but the related experiments remain in the trial stage. Therefore, we assessed the safety and evaluated the efficacy of combined cytoreductive surgery and early postoperative intraperitoneal chemotherapy (EPIC) in gastric cancer patients with peritoneal carcinomatosis of gastric cancer. From Nov. 1997 to May. 2002, eighteen cases of combined cytoreduction and EPIC were performed in the Korea Cancer Center Hospital due to gastric cancer with peritoneal carcinomatosis. The control group consisted of 33 patients who had no resection without EPIC during the same periods. After combined cytoreductive surgery and EPIC, all patients received systemic chemotheraphy with the exception of 2 patients who could not tolerate the treatment. We retrospectively investigated the clinicopathologic features and analyzed the factors affecting the prognosis. Median follow-up period was 11.9 months (range 0.5~61 months). Statistical analysis was performed by SPSS 11.0 for Windows. A P-value less than 0.05 was considered as statistically significant. There was one case of the treatment-related mortality (5.5%) and seven cases of treatment-related complications (38%) in the combined cytoreductive surgery and intraperitoneal chemotherapy group. One-, 3- and 5-year survival rates of cytoreductive surgery plus EPIC were 57.6%, 25.9% and 13.0%, respectively, and those of the control group were 18.2%, 3% and 0%, respectively. Survival of the combined cytoreductive surgery plus EPIC group was better than that of the control group (p=0.0026). In multivariate analysis of prognostic factors affecting the survival, combined cytoreductive surgery plus EPIC (p=0.02) and systemic chemotherapy (p=0.019) were independent prognostic factors. Although a small number of cases were included in this study, combined cytoreductive surgery plus EPIC showed survival benefit and retained a comparable complication rate compared with the control group.

Comparison of outcomes of viscocanalostomy and phacoviscocanalostomy

Background: Many adults who undergo glaucoma filtering surgery also need surgical treatment of coexisting cataract. Recent reports of the use of new alternative nonpenetrating techniques in combination with phacoemulsification have given encouraging results. The purpose of this study was to compare the safety and efficacy of viscocanalostomy and phacoviscocanalostomy in the management of medically uncontrolled open-angle glaucoma.Methods: Twenty patients who underwent phacoviscocanalostomy in one eye each were enrolled in the study. Twenty matching patients who underwent viscocanalostomy in one eye each at our institution were selected as the control group. Postoperative reductions in intraocular pressure (10P) and number of antiglaucoma medications were compared between the groups. Visual acuity and complications were secondary outcomes.Results: Significant reductions of IOP and of use of antiglaucoma medication occurred in both groups (p < 0.05) these results were comparable in the two groups (p>0.05). The mean IOP reduction was 34% in the eyes that underwent viscocanalostomy alone and 38% in the eyes that underwent phacoviscocanalostomy. The success rates of the two procedures were also comparable (p>0.05). In the combined-surgery group the best-corrected visual acuity improved by 2 or more lines in 18 eyes (90%). Intraoperative complications did not occur in either group.Interpretation: Combining phacoemulsification with viscocanalostomy did not have a negative effect on the 10P control achieved by viscocanalostomy alone and did not increase the complication rate. Phacoviscocanalostomy was safe and effective in the surgical management of eyes with both glaucoma and cataract.