High Surgical Success Rate Research Articles

Does Postoperative Near Visual Acuity Predict Macular Hole Closure?

To determine whether prone postoperative near visual acuity following macular hole surgery can be used as a reliable indicator of successful hole closure, data from 21 patients undergoing macular hole surgery were collected. Seventeen of the 18 patients with hole closure and all 3 patients with persistent macular holes had a Rosenbaum acuity better than preoperative visual acuity, yielding 94% sensitivity, 0% specificity, 85% positive predictive value, and 0% negative predictive value. Fourteen of the 18 patients with macular hole closure and all 3 patients with persistent macular holes had a Rosenbaum acuity better than 20/40, yielding 78% sensitivity, 0% specificity, 82% positive predictive value, and 0% negative predictive value. Although postoperative near visual acuity can predict macular hole closure with 94% sensitivity, the test is not clinically useful to predict hole closure because of the high surgical success rate of macular hole surgery. The test could be useful in encouraging patients to maintain head prone positioning and alleviate patient anxiety.

Usefulness of combination of high-resolution ultrasonography and dual-phase dual-isotope iodine 123/technetium Tc 99m sestamibi scintigraphy for the preoperative localization of hyperplastic parathyroid glands in renal hyperparathyroidism

The usefulness of both dual-phase dual-isotope iodine 123 ( 123 I)/technetium Tc 99m ( 99m Tc) sestamibi scintigraphy and ultrasonography for the detection of hyperplastic parathyroid glands secondary to renal hyperparathyroidism is rarely addressed; most studies focus on primary hyperparathyroidism. However, it may be crucial to identify and accurately localize hyperplastic glands before surgery. To study the usefulness of high-resolution ultrasonography (performed by both the radiologist and surgeon) and dual-phase dual-isotope 123 I/ 99m Tc sestamibi scintigraphy in patients with renal hyperparathyroidism, a series of 20 patients consecutively referred for parathyroidectomy was studied prospectively. Results of both examinations, independently scored, were correlated with surgical and histopathologic findings for each hyperplastic parathyroid gland localization. All parathyroid glands except 1 were found during primary surgery consisting of a subtotal parathyroidectomy (success rate, 99%). The missed gland was removed successfully 1 month later. Neither supernumerary nor ectopic glands were found. Mean weight of totally removed parathyroid glands was 633 mg. Ultrasonography detected 75% of hyperplastic parathyroid glands; dual-phase 123 I/ 99m Tc sestamibi scintigraphy, 66%; and a combination of both, 88%. Most missed glands at scintigraphy corresponded to superior glands, whereas false-negative results at ultrasonography correlated with low gland weight. Combined ultrasonography and 123 I/ 99m Tc sestamibi scintigraphy should be considered for routine use to localize hyperplastic parathyroid glands in patients with renal hyperparathyroidism undergoing surgery. We suggest performing scintigraphy first, before ultrasonography, to guide the radiologist to areas of hyperfunctioning glands. In our experience, this proved very helpful in achieving a high surgical success rate in patients with renal hyperparathyroidism, especially when the surgeon visualizes the parathyroid glands at ultrasonography.

Results of tonsillectomy for obstructive sleep apnea syndrome in adults with tonsillar hypertrophy

High surgical success rates for adenotonsillectomy in children with obstructive sleep apnea (OSAS) have been described in various studies. The purpose of this study was to evaluate the efficiency of bilateral tonsillectomy. Data from a retrospective study with eight adults (six males, two females; average age 29.0 years old; average body mass index, 27.3±5.3 kg/m 2) who underwent tonsillectomy for OSAS were evaluated based on the severity level of the preoperative apnea–hypopnea index (AHI). Within 1.0 year, eight patients with a substantial tonsillar hypertrophy underwent attended polysomunography. Tonsillectomy was performed, and postoperative complications and polysomunographic findings were reviewed. The severity of OSAS was rated mild with an AHI of 10–29, moderate with an AHI of 30–49, and severe with an AHI of equal to or greater than 50. Four of eight patients exhibited severe OSAS, three patients had moderate OSAS, and one patient was of mild OSAS. The surgical response rates (defined as decrease in the postoperative AHI ≧50%) were 75% in severe apneics and 100% in moderate or mild apneics. No serious complications occurred. In the carefully selected patient, a tonsillectomy should be considered an effective and safe surgical option for the treatment of OSAS.

Surgical results of patients with a-pattern horizontal strabismus

Purpose To investigate the surgical results of patients having horizontal strabismus with A-pattern associated with superior oblique overaction (SOOA). Methods Twenty patients with horizontal strabismus (12 exotropia [XT] and 8 esotropia [ET] with no previous strabismus surgery) with SOOA-associated A-pattern were analyzed retrospectively. Motor success was defined as a horizontal deviation of 8 prism diopters ( PD) or less, 6 PD or less of vertical deviation in all gazes, and no greater than 8 PD of A-pattern. Stereoacuity was measured using the Titmus test (Stereo Optical, Chicago, IL). Results Sixty percent of patients had successful results at the final examination. No significant difference was found between the XT and ET patients in preoperative and postoperative horizontal deviations in the primary position, A-pattern collapse, or success rate ( P > .05). Four patients had an induced postoperative vertical deviation. Among eight patients without stereoacuity preoperatively, four showed an average of 910 seconds of arc (40 to 3000 seconds of arc) after surgery. Conclusion Simultaneous surgery on the horizontal and SO muscles in patients with horizontal strabismus with SOOA-associated A-pattern can achieve a relatively high surgical success rate and restore binocular function.

Ultrasound biomicroscopy and intraocular-pressure-lowering mechanisms of deep sclerectomy with reticulated hyaluronic acid implant

Purpose To evaluate the anatomic characteristics and intraocular pressure (IOP) lowering mechanisms of deep sclerectomy with reticulated hyaluronic acid implant (DS with RHAI) using ultrasound biomicroscopy (UBM). Setting Eye Clinic, Department of Neurological and Vision Sciences, University of Verona, Verona, Italy. Methods Thirty patients with primary open-angle glaucoma not controlled by medical therapy had DS with RHAI in 1 eye. A complete ocular examination and UBM study were performed 1, 3, 6, and 12 months postoperatively and thereafter at 6 month intervals. Eleven parameters were evaluated, the most important of which were IOP, surgical success in lowering IOP to 21 mm Hg or less with or without additional medical therapy, UBM appearance of the site of DS with RHAI, size of the decompression space, presence of a filtering bleb and supraciliary hypoechoic area, and scleral reflectivity around the decompression space. Results After a mean follow-up of 11.4 months ± 4.7 (SD), the mean percentage reduction in IOP compared to preoperatively was 38% (from 26 ± 4.5 mm Hg to 16.2 ± 3.8 mm Hg; P = .0001). Twenty-four patients (80%) had an IOP less than 21 mm Hg; however, 7 of these eyes (23%) required additional IOP-lowering medical therapy. The operation failed in 6 patients (20%) despite additional therapy. Ultrasound biomicroscopy revealed a reduction in the size of the decompression space from 6 months postoperatively and its disappearance in 2 cases. The difference in size at the last follow-up and at 1 month postoperatively (maximum length 2.41 ± 1.02 mm versus 3.53 ± 0.51 mm) was significant ( P = .0001). At the last examination, a filtering bleb was present in 18 patients (60%), a supraciliary hypoechoic area in 18 (60%), and hyporeflectivity of the scleral tissue around the decompression space in 14 (47%). These 3 UBM characteristics were detected singly and in various combinations. The simultaneous presence of all 3 characteristics in the same eye correlated significantly with a higher surgical success rate ( P = .004). Conclusions Ultrasound biomicroscopy showed that filtering bleb formation was frequent in eyes having DS with RHAI but that it was not the only surgically induced IOP-lowering mechanism. Increased uveoscleral and transscleral filtration may be equally important.

Tonsillectomy as a treatment of obstructive sleep apnea in adults with tonsillar hypertrophy.

High surgical success rates for adenotonsillectomy in children with sleep-related breathing disorders have been described in various studies. The purposes of the present study were to observe how often a substantial tonsillar hypertrophy is associated with obstructive sleep apnea (OSA) in adults and to evaluate the efficiency of a bilateral tonsillectomy. Data from a prospective study with 11 adults who underwent tonsillectomy as single treatment for sleep-related breathing disorders were evaluated based on the severity level of their preoperative apnea-hypopnea index (AHI). Within 3 years, 11 patients with a substantial tonsillar hypertrophy underwent attended polysomnography in the sleep laboratory. Tonsillectomy was performed, and postoperative complications and polysomnographic findings were reviewed. Follow-up time was 3 to 6 months. Nine of 11 patients (81.8%) were diagnosed with OSA. Five of these patients exhibited severe OSA, four patients had mild OSA, and two patients were simple snorers with an AHI below 10. The surgical response rates (defined as decrease in the postoperative AHI > or = 50% and a postoperative AHI of less than 20) were 80.0% in severe apneics and 100% in mild apneics. No serious complications occurred. Substantial tonsillar hypertrophy can rarely cause OSA in adults. In the carefully selected patient a tonsillectomy should be considered an effective and safe surgical option for the treatment of this disorder.

Multilevel pharyngeal surgery for obstructive sleep apnea: Indications and techniques

Patients with moderate to severe obstructive sleep apnea generally manifest upper airway obstruction and collapse at multiple levels. After these collapsing segments are identified preoperatively, the surgical approach should be customized to address the obstruction in a site-specific way. The combination of palatopharyngoplasty with both a hyoid myotomy and a mandibular osteotomy with tongue advancement provides a high rate of surgical success and is described in detail, along with a logical algorithm for patient selection.

Contemporary Surgical Approaches to Upper Airway Reconstruction in Sleep-Disordered Breathing

Objective: To assess the efficacy of surgical approaches for upper airway reconstruction in simple snoring and sleep-disordered breathing, using laser-assisted uvulopalatoplasty (LAUP), uvulopalatopharyngoplasty (UPPP), genioglossus advancement, hyoid myotomy, and maxillomandibular osteotomy. Patients and Methods: A retrospective study of consecutively surgically treated patients with simple snoring or sleep-disordered breathing was performed. Twenty-two patients underwent treatment by LAUP, 23 by UPPP, and 12 by a phased surgical approach that included phase I surgery (UPP, genioglossus advancement, and hyoid myotomy) as the initial procedure and, if residual airway obstruction persisted, phase II surgery (maxillomandibular osteotomy). Results: The main outcome measures included improvement of excessive daytime sleepiness and improvement in objective sleep parameters: respiratory disturbance index (RDI) and lowest oxygen saturation (LSAT). For the patients undergoing phased airway reconstruction, the mean preoperative data included a RDI of 45.6, a LSAT of 80.9%, and an Epworth Sleepiness Scale score of 11.6. The responders of phase I surgery (7/11) revealed a change in the mean RDI from preoperatively to postoperatively of 32.0 to 3.6, LSAT of 82.6 to 91%, and Epworth Sleepiness Scale score of 9.3 to 6.8. The nonresponder group (4/11) revealed a change in the mean RDI of 69.3 to 55.6, LSAT of 78 to 77%, and Epworth Sleepiness Scale score of 14.0 to 7.7. Both patients undergoing phase II surgery were successfully treated. LAUP resolved snoring in 80.1% and UPPP in 90.9%. Conclusion: UPPP and LAUP are moderately effective procedures for resolving snoring. Phase I upper airway reconstruction using UPPP, genioglossus advancement, and hyoid suspension and phase II maxillomandibular advancement surgery offer a high surgical success rate in a disease that may need a stepwise approach to its management.

내시경과 Nd-YAG Laser를 사용한 선천성 후비공폐쇄의 치료

Choanal atresia is a congenital anomaly usually diagnosed at birth. The transnasal endoscopic route offers excellent visualization of the posterior choana, so the ability to open the defect widely with a high surgical success rate. Recently we have treated a case of unilateral membranous type using Nd：YAG laser. The advantage of the Nd：YAG laser is its fiber-optic delivery, allowing the laser to be hand-held, giving greater precision. Laser ablation of the obstructing tissues was attempted through a videoendoscope. The procedure was found to be safe, quick, with minimal morbidity and a shorter in-patient stay. Good nasal airway was achieved. We present the result of the transnasal endoscopic approach using Nd：YAG laser with review of literature. (J Clinical Otolaryngol 1999;10:87-89)

Transnasal endoscopic repair of congenital choanal atresia: long-term results.

To evaluate the short- and long-term success of the repair of congenital choanal atresia using the transnasal endoscopic approach with and without power instruments. Retrospective case series in a tertiary care center. Fifteen patients with either unilateral or bilateral congenital choanal atresia were treated using the transnasal endoscopic approach. Postoperative stenting was used in all 15 patients. The senior surgeon (C.W.G.) currently uses the transnasal endoscopic drill-out technique. We describe our experience and long-term follow-up of 15 patients (9 with unilateral atresia, 5 with bilateral atresia, and 1 with unilateral stenosis) who were treated with the use of the transnasal endoscopic technique during a 7-year period. In 8 patients, the transnasal endoscopic technique was performed using conventional biting instruments, and in 7 patients, the transnasal endoscopic technique with power instruments was used. The patency of the surgical repair of congenital choanal atresia by the transnasal endoscopic approach. Of 14 patient procedures, 12 remained patent. One patient required minor debridement of granulation tissue 1 week following stent removal, and 1 patient required surgical transnasal revision 2 months after the primary procedure, with a patent result after the second procedure. Despite patent choanae being achieved, 1 patient died of cardiac anomalies 8 months after the atresia repair. The transnasal endoscopic route offers excellent visualization of the posterior choana and, hence, the ability to open the defect widely with a high surgical success rate. Newer powered instrumentation further enhances the ability to perform this technique cleanly.

Contribution of neuropsychological data to the prediction of temporal lobe epilepsy surgery outcome.

We empirically examined the contribution of neuropsychological data to the prediction of postoperative seizure control relative to base rate information in an existing series of patients undergoing anterior temporal lobectomy (ATL). A discriminant function predicting surgery outcome (seizure-free vs. non-seizure-free) was computed separately for samples of patients with left (n = 79) and right (n = 62) temporal lobectomy (LATL, RATL). Predictor variables included 14 measures tapping five neurocognitive domains. The predicted base rates were compared with the actual base rates in the two samples. Finally, overall predictive accuracy was examined in optimal versus suboptimal ATL patients. The base rate of seizure freedom in the LATL group was 74.70%; that in the RATL group was 66.10%. The predictive function for the LATL group achieved a hit rate of 80.00% and a positive predictive power of 92.11%. The function for the RATL group achieved a hit rate of 83.33% and a positive predictive power (PPP) of 89.66%. The overall predictive accuracy for the optimal group was only 55%, but that in the suboptimal group was 72%. Neuropsychological data used in a multivariate statistical fashion may be able to offer an incremental increase in the prediction of postoperative seizure freedom relative to existing base rates of surgery success in patients with ATL epilepsy. The use of neuropsychological data may be of greatest predictive value in a population of ATL candidates with suboptimal findings with a lower base rate of postoperative seizure freedom, but may actually reduce predictive accuracy in a group of ATL candidates from an optimal population with an already high base rate of surgical success.

Retinal detachment caused by retinal dialysis.

To determine the characteristics of patients developing retinal detachment secondary to retinal dialysis in Western Australia and to confirm the clinical impression that these patients had a low rate of proliferative vitreoretinopathy (PVR). A retrospective analysis of the records of 1601 consecutive patients with rhegmatogenous retinal detachment identified 71 patients in whom the retinal detachment was caused by a retinal dialysis. The majority of these patients were young adults (mean age of 30 years) and the male to female ratio was 1.3:1. Seventy per cent of patients provided a history of significant trauma to the affected eye. Sporting injuries, assault, and motor vehicle injuries together accounted for 72% of identifiable trauma. Examination revealed a dialysis of the inferotemporal quadrant in 75% of cases and despite obvious signs of chronicity of the associated retinal detachment (such as intraretinal macrocysts and demarcation lines) in approximately one-third of the eyes, only 5.6% developed grade CI PVR either pre- or postoperatively. The present study supports the view that it is the low rate of PVR that explains the good prognosis and high surgical success rate for retinal detachments caused by retinal dialysis. It is postulated that a major reason for the low rate of PVR is that the vitreous base attachment to the posterior margin of a retinal dialysis acts as a significant barrier to the migration of potentially proliferative retinal pigment epithelial cells. This may lead to containment of the responsible proliferative cells within the loculated subretinal space.

Diagnostic Delay and Outcome in Surgery for Type A Aortic Dissection

Twenty-two patients with acute type A aortic dissection presented to this hospital over a three-year period. The initial diagnosis was incorrect in 12 (54.5 per cent) and in 11 of these the error occurred in peripheral hospitals before referral. This diagnostic mistake lead to a delay in surgical treatment of 2-9 days (median 5 days). Three deaths occurred without surgery, and two of these could have been considered for repair if the correct diagnosis had been made earlier. In the surgically treated group, a 30-day survival of 16 out of 19 (84.2 per cent) was achieved and the three deaths were all related to late referral. Two died because of bowel infarction and one because of respiratory failure. An increased general awareness of acute aortic dissection is necessary as early diagnosis, before the onset of irreversible ischaemic events, allows a high surgical success rate.

Ureteropelvic junction obstruction during the first year of life

Over the past three years, 28 children less than one year of age, were operated on for ureteropelvic junction obstruction. Our results demonstrate that congenital hydronephrotis most commonly presents antenatally, and that early postnatal correction can be performed safely. The high surgical success rate, with a relatively short hospital stay (3–4 days), is attributed to early diagnosis, when the pelviureteral tissues are relatively healthy and nephron maturation is at maximum. The practice of delaying surgical correction of an obstructed hydronephrotic kidney on the basis of “stable” renal function is unwarranted, since it denies such kidneys their full potential for recoverability.

Computed tomography in degenerative lumbar spinal stenosis: The value of multiplanar reconstruction

Computed tomography is superior to other radiologic modalities for evaluating degenerative lumbar spinal stenosis, because it directly images both bone and soft tissue. CT multiplanar reconstruction provides precise three dimensional analysis. Correlation of CT with myelography and clinical information leads to the following conclusions. 1. Severe central canal stenosis on CT corresponds to high grade or complete block on myelography. 2. Lateral recess encroachment is best identified on transaxial CT images and is the most common type of persistent stenosis in this series of postoperative patients. 3. Narrowing of the neural foramina is best demonstrated on CT sagittal reconstruction images. 4. Intraarachnoidal adhesions require intrathecal contrast agents (e.g., metrizamide) for radiographic demonstration. 5. Multiplanar reconstruction images are very helpful for accurately describing the spatial relationships involved in spinal disease. 6. Degenerative spondylolisthesis can be reliably characterized by CT and distinguished from spondylolytic forms of spondylolisthesis. The "double margin" sign is a reliable transaxial CT finding in all forms of spondylolisthesis. 7. A close correlation exists between CT-demonstrated moderate to severe postoperative stenosis and poor surgical results. Improved diagnostic imaging and interpretation leads to better preoperative planning and higher surgical success rates. Radiographic abnormalities do not necessarily produce clinically significant patient symptoms. Careful clinical correlation is required for successful treatment planning and patient management.