Modern Surgical Approaches Research Articles

Mechanical prophylaxis, early mobilisation and risk stratification: as effective as drugs for low risk patients undergoing primary joint replacement. Results in 13,384 patients

IntroductionCurrent NICE Guidelines state that all patients undergoing total hip and knee arthroplasty should be given both mechanical and chemical prophylaxis. At our institution, a targeted thromboprophylaxis policy has been in place since October 1999. The aim of this study was to calculate our venous thromboembolism rates and compare these to published rates in the literature. MethodsAll patients are pre-operatively assessed for their VTE risk. Patients are stratified into high or low risk: all patients received mechanical thromboprophylaxis and the higher risk patients now receive chemical and mechanical thromboprophylaxis post op. Patients are reviewed at 2, 6 and 52 weeks and with annual postal questionnaires and clinical and radiological review at 5 and 10yrs. Results13,384 primary THA and TKAs were entered into the database. The overall rate of clinically apparent DVT and overall PE rates of 0.48% and 0.42% respectively. 86.16% of our patients were low risk, of these 23.3% of patients were on Aspirin/Clopidogrel with mechanical thromboprophylaxis and 76.7% of patients had mechanical prophylaxis alone. There was no statistical difference between the DVT or PE rates in the low risk groups. ConclusionOur results show that use of early mobilisation and mechanical prophylaxis within an Enhanced Recovery Programme results in comparable VTE rates to chemical prophylaxis for all, which is reflected in the literature. Our results question the need for chemical thromboprophylaxis or extended use of mechanical thromboprophylaxis in “lower risk” patients if a risk stratification policy is used in the context of modern surgical approaches.

STRICTUREPLASTY AS AN ORGAN-SAVING METHOD IN PATIENTS WITH SMALL BOWEL CROHN'S DISEASE (case report)

Crohn's disease (CD) is a complex, chronic recurrent disease with transmural, segmental, granulomatous inflammation in all parts of the gastrointestinal tract with high risk of local and systemic complications. The disease is progressive, despite a wide range of modern conservative and surgical approaches. One of the most common causes of surgery for CD is strictures, which are result of prolonged, non-specific inflammation and later cicatricial changes in the intestinal wall. The occurrence of strictures is a serious clinical problem, due to the lack of effective methods of diagnosis and treatment. In fact, there are two type of surgery – resection of the affected area and organ-saving procedure. At the same time, when performing extensive resections of the small bowel, the patient loses a large area of absorption surface, which often leads to the short bowel syndrome. Recently, the majority of foreign experts prefer organ-saving procedure – strictureplasty. In this paper, we present a case of successful application of this procedure for complicated form of Crohn's disease.

Gene Therapy Tools for Brain Diseases.

Neurological disorders affecting the central nervous system (CNS) are still incompletely understood. Many of these disorders lack a cure and are seeking more specific and effective treatments. In fact, in spite of advancements in knowledge of the CNS function, the treatment of neurological disorders with modern medical and surgical approaches remains difficult for many reasons, such as the complexity of the CNS, the limited regenerative capacity of the tissue, and the difficulty in conveying conventional drugs to the organ due to the blood–brain barrier. Gene therapy, allowing the delivery of genetic materials that encodes potential therapeutic molecules, represents an attractive option. Gene therapy can result in a stable or inducible expression of transgene(s), and can allow a nearly specific expression in target cells. In this review, we will discuss the most commonly used tools for the delivery of genetic material in the CNS, including viral and non-viral vectors; their main applications; their advantages and disadvantages. We will discuss mechanisms of genetic regulation through cell-specific and inducible promoters, which allow to express gene products only in specific cells and to control their transcriptional activation. In addition, we will describe the applications to CNS diseases of post-transcriptional regulation systems (RNA interference); of systems allowing spatial or temporal control of expression [optogenetics and Designer Receptors Exclusively Activated by Designer Drugs (DREADDs)]; and of gene editing technologies (CRISPR/Cas9, Zinc finger proteins). Particular attention will be reserved to viral vectors derived from herpes simplex type 1, a potential tool for the delivery and expression of multiple transgene cassettes simultaneously.

SURGERY OF THORACIC DISC HERNIATION: A SYSTEMATIC REVIEW OF ENGLISH-LANGUAGE LITERATURE

The presented review of scientific publications from the Medline (PubMed) and Scopus databases considers modern surgical approaches used to remove intervertebral hernias in the thoracic spine. The advantages and disadvantages of anterior and posterior approaches are analyzed. It has been revealed that the anterior approaches, providing a good opportunity to remove a hernia, are associated with the risk of serious complications, including pulmonary ones, and often lead to the formation of a post-thoracotomy pain syndrome. Mini-thoracotomy and percutaneous thoracoscopy, although less invasive, do not exclude the development of complications inherent in conventional thoracotomy. Modern posterior approaches are less traumatic and allow, with minimal contact with the spinal cord, to successfully remove not only soft tissue, but also ossified disc herniation. The choice of the optimal method of discectomy remains an unsolved problem and depends on practical skills, experience and preferences of the surgeon. For an objective and reliable assessment of the efficiency of surgical technologies and the determination of optimal indications for each of them, a prospective multicenter study is necessary.

A Systematic Review of Utility Score Assessments in the Breast Surgery Cost-Analysis Literature.

Surgery for breast cancer can have significant impact on patient quality-of-life. Cost-utility analysis provides a way to analyze the economic impact of a surgical procedure with the change in a patient's quality of life. Utility scores are used in these analyses to quantify the impact on quality of life. We undertook a systematic review of the literature on breast cancer surgical procedures to compile a repository of utility scores and to assess gaps in the current literature. Following PRISMA guidelines, a systematic review was performed for studies reporting utility scores for breast surgery and breast reconstruction. The health states and utility scores were extracted and grouped into seven procedural categories based on oncologic and reconstructive methods. Mean utility score and ranges were calculated and reported for each procedural category. Nineteen articles met the inclusion criteria assessing 118 health states. Most utility scores were obtained from healthcare professionals. Breast-conserving therapy yielded the highest mean utility score at 0.79, whereas mastectomy yielded a mean utility score of 0.75. Among reconstruction health states, implant reconstruction had a lower score than autologous reconstruction (0.64 implant vs. latissimus dorsi 0.69 and TRAM/DIEP 0.71). No utility scores were found associated with oncoplasty or nipple-sparing mastectomy procedures. A reliable body of utility scores is important in enabling future cost-utility and value-based analysis comparisons for breast surgical oncology. Additional work is needed to obtain health state assessments from the patient perspective, as well as assessment of more modern surgical and reconstructive approaches.

Long-term clinical and radiographic outcomes and patient satisfaction after adult spinal deformity correction.

Adult spinal deformity surgery has increased with the aging population and modern surgical approaches, although it has high complication and reoperation rates. The permanence of radiographic correction, mechanical complications, predictive factors for poor patient-reported outcomes, and patient satisfaction were analyzed. A total of 79 adult patients were retrospectively analyzed at baseline and 1-9 years after adult spinal deformity correction between 2007 and 2016. Patient-reported outcomes (Oswestry Disability Index, visual analog scale, and Scoliosis Research Society-30 scores), changes in radiographic alignment, indications for reoperation, predictors of poor outcomes according to the Oswestry Disability Index and Scoliosis Research Society-30 scores, and patient satisfaction with management were studied. Oswestry Disability Index and visual analog scale scores (p = 0.001), radiographic correction of thoracic kyphosis, lumbar lordosis, and pelvic retroversion (p ⩽ 0.001) and sagittal vertical axis (p = 0.043) were significantly better at 4-5 years of follow-up than at baseline. The risk for the first reoperation owing to mechanical failure of instrumentation or bone was highest within the first year, at 13.9% (95% confidence interval = 8.0%-23.7%), and 29.8% (95% confidence interval = 19.4%-43.9%) at the 5-year follow-up. Oswestry Disability Index and Scoliosis Research Society-30 total scores had a good correlation (r = -0.78; 95% CI = -0.86 to -0.68; p < 0.001). Satisfaction with management was correlated with patient-reported outcomes. Male sex and depression (p = 0.021 and 0.018, respectively) predicted poor outcomes according to the Oswestry Disability Index and/or Scoliosis Research Society-30 score. The achieved significant radiographic correction was maintained 5 years postoperatively. Despite reoperations, patient satisfaction and clinical outcomes were good. Depression and male sex predicted poor clinical outcomes.

Orbital Decompression for Thyroid-Related Orbitopathy During the Quiescent Phase.

To describe historical and modern surgical approaches to orbital decompression in patients with thyroid-related orbitopathy in the quiescent phase. A literature review of published techniques using the National Institutes of Health PubMed database. Historically, orbital decompression has been accomplished via transantral, transcranial, transnasal, and orbital approaches. Current techniques use predominately periocular incisions to achieve effective decompression and proptosis reduction. Based on exophthalmometry and desired proptosis reduction, the authors propose a graded surgical approach to decompression for thyroid orbitopathy beginning with fat reduction, followed by deep lateral orbit via a superior eyelid crease incision, then medial wall by retro-caruncular approach, then posterior medial orbital floor either via transconjunctival or swinging eyelid approach, and finally with lateral orbital rim removal by superior eyelid crease incision as needed. These approaches can result in a range of proptosis reduction of up to 10 mm. A structured approach to orbital decompression results in predictable and effective outcomes in proptosis reduction.

Head and neck cancer: improving outcomes with a multidisciplinary approach.

For early-stage head and neck cancer (HNC), surgery (S) or radiotherapy (RT) is a standard treatment. The multidisciplinary approach, which includes multimodality treatment with S followed by RT, with or without chemotherapy (CT) or concurrent chemoradiotherapy (CRT), is required for locally advanced head and neck cancer (LAHNC). CRT improves prognosis, locoregional control (LRC), and organ function in LAHNC, compared to RT alone. Prognosis in recurrent/metastatic HNC (R/M HNC) is dismal. Platinum-based CT, combined with the anti-Epidermal Growth Factor Receptor (EGFR) antibody (Ab) cetuximab, is used in first-line setting, while no further validated options are available at progression. The complexity of disease is, in part, due to the heterogeneity of organs and functions involved and the need for a multimodality approach. In addition, the patient population (often elderly and/or patients with smoking and alcohol habits) argues for an individually tailored treatment plan. Furthermore, treatment goals – which include cure, organ, and function preservation, quality of life and palliation – must also be considered. Thus, optimal management of patients with HNC should involve a range of healthcare professionals with relevant expertise. The purpose of the present review is to 1) highlight the importance and necessity of the multidisciplinary approach in the treatment of HNC; 2) update the knowledge regarding modern surgical techniques, new medical and RT treatment approaches, and their combination; 3) identify the treatment scenario for LAHNC and R/M HNC; and 4) discuss the current role of immunotherapy in HNC.

Surgical Treatment of Tattoo Complications.

With a continuing increase in the number of tattoos performed worldwide, the need to treat tattoo complications is growing. Earlier treatments of chronic inflammatory tattoo reactions were dominated by a medical approach, or with no active intervention. In this chapter, we will address modern surgical approaches applied to situations when medical treatment is inefficient and lasers are not applicable. Dermatome shaving is positioned as first-line treatment of allergic tattoo reactions and also indicated in a number of other tattoo reactions, supplemented with excision in selected cases. The methods allow fundamental treatment with removal of the culprit pigment from the dermis. The different instruments, surgical methods, and treatment schedules are reviewed, and a guide to surgeons is presented. Postoperative treatments and the long-term outcomes are described in detail. An algorithm on specialist treatment and follow-up of tattoo reactions, which can be practiced in other countries, is presented.

Is cardiac surgery feasible in heart failure patients older than 80 years?

Octogenarians affected by chronic heart failure frequently present with multiple comorbidities and a certain degree of intrinsic frailty. These clinical features are associated with an increased operative risk and can nullify the improvements in survival and quality of life that can be obtained with modern surgical approaches. Accurate patient selection is therefore of crucial importance. To this purpose, many scores are available to define the surgical risk, while more efforts should be made to improve our knowledge regarding expected and actual quality of life. Given this highly complex scenario, a comprehensive Heart Team approach is strongly advisable, aimed at tailoring strongly individualized surgical programs. Indeed, in such fragile patients there is often no need to pursue a complete surgical therapy, and optimal results are obtained identifying and treating the culprit pathology, while wisely omitting to treat the unnecessary elements. Moreover, these patients take major advantages from preoperative clinical optimization and a step-by-step delayed approach. Given this premise, modern coronary artery bypass grafting, aortic valve replacement and mitral valve repair/replacement, which are the most frequent procedures in these patients, are feasible and reasonably safe and effective. New technologies are emerging to treat high-risk and inoperable patients, and promise to expand therapeutic frontiers for older chronic heart failure patients; these new devices, however, should never forget the Heart Team approach.

Modern surgical approaches in treatment of simple solitary, multilocular, multiple cysts and polycystic kidney disease in children

In a review of current literature, the evolution of technology of endovideosurgical treatment approaches of simple solitary, multilocular, multiple cysts and polycystic kidney disease in children is presented. The article describes different puncture, «open», retroperitoneoscopic and laparoscopic types of surgical interventions used in this disease, their negative and positive aspects. Over the past two decades, endoscopic surgery for cystic kidney disease minimize surgical trauma so that they became comparable to puncture techniques, and surpass them in the intervention radicality. Herewith cosmetic effect is not inferior to that when using puncture techniques. When comparing videoscopic with «open» operations, the advantage of the first in a traumatic effect on the child’s body, and cosmetic results also were noted, while the surgical treatment radicality of compared techniques was identical. Presented statistical data obtained from the international literature analysis (more than 500 cases of endovideosurgical treatment of cystic kidney disease in 22 hospitals) demonstrate the short duration of surgery, short-term hospitalization and a high proportion of treatment success up to 90-100%. The comparative analysis of surgical procedures performed in the renal cysts endoscopic fenestration performance by retroperitoneal access is conducted. All presented in the literature review surgery methods are original and can be used in the treatment of children with cystic kidney disease, however, each operation has its own complexities of the technical performance. In this connection, the search for the best method of surgical treatment that can become the «gold standard» treatment for children with cystic kidney disease continues. In conclusion, it is noted that endovideosurgical methods of treatment of solitary, multilocular, multiple cysts and polycystic kidney disease in children have excellent prospects for the widespread implementation in pediatric urology and andrology.

Problem of Colorectal Cancer in India and Issues Related to Management

Abstract Colorectal cancer (CRC) in India ranks amongst the lowest in comparison to most parts of the world. However, the sheer population of the country and increasing urbanization, coupled with greater awareness and scope of detection, has resulted in a gradual increase in numbers to the point that it ranks amongst the commonest cancers in India. This review discusses the relevance of specialization in CRC surgery in India and also important aspects of multidisciplinary care such as advances in chemotherapy and radiotherapy. This article also deals specifically with the problem of rectal cancer in young Indians. Furthermore, the impact of minimal access CRC surgery and cutting edge issues in CRC surgery such as approach to complete responders after neo-adjuvant treatment in rectal cancer, concepts in sphincter preservation, and dealing with metastatic CRC are also addressed. Lastly, modern molecular biology with a clinical relevance and modern surgical approaches such as TEMS and TAMIS are also discussed.

Prevalence of atrial tachyarrhythmia in adults after Fontan operation

ObjectivesThe Fontan procedure provides palliation for patients with complex congenital heart disease. A late complication is the development of a pro-arrhythmogenic environment. Modifications to the surgical technique try and reduce...

Outcomes of 807 Thompson hip hemiarthroplasty procedures and the effect of surgical approach on dislocation rates

The majority of displaced intracapsular fractures in our unit are managed with a Thompson hip hemiarthroplasty. Recent UK guidance from the National Institute for Health and Care Excellence has, however, advised against the continued used of the Thompson implant in patients with hip fracture. The aim of this study was to review the outcomes and complications after Thompson hip hemiarthroplasty, including the impact of modern surgical approaches and cementing, whilst controlling for confounding factors.We reviewed the outcomes following Thompson hip hemiarthroplasty from a series of 807 cases performed between April 2008 and November 2013. Of these, 721 (89.3%) were cemented and 86 (10.7%) uncemented. A total of 575 (71.3%) procedures were performed in female patients. The anterolateral approach was performed in 753 (93.3%) and the posterior approach with enhanced soft tissue repair in 54 (6.7%).Overall, there were 23 dislocations (2.9%). Dislocation following the posterior approach occurred in 13.0% (seven of 54) in comparison to 2.1% (16 of 753) with the anterolateral approach (odds ratio (OR) 8.5 (95% confidence interval (CI) 2.8–26.3), p<0.001). Patients were discharged home in 459 cases (56.9%), to a care home or other hospital in 273 cases (33.8%). Of the total number of patients, 75 died during their admission (9.3%), and 51.8% (338 of 653) returned home within 30 days. The 30-day mortality was 7.1% (57 cases) and the 1-year mortality was 16.6% (116 of 699).We recommend against the continued use of the posterior approach in hip hemiarthroplasty, as enhanced soft tissue repair did not reduce the dislocation rates to an acceptable level in this series utilising the Thompson implant. Our findings, however, demonstrate satisfactory results for patients treated with the Thompson hip hemiarthroplasty performed through an anterolateral approach. We suggest that the continued use of this implant in a carefully selected patient cohort is justifiable.

Open globe injury with intraocular foreign body and traumatic cataract

Penetrating ocular trauma is an important cause of visual loss in children and young adults. The fate of the traumatized eye depends on the treatment adopted, with early reporting and appropriate surgical management reducing the visual loss. With the use of modern diagnostic techniques, surgical approaches, and rehabilitation, many eyes can be salvaged with retention of vision. We report a patient who presented with sudden visual loss, corneal laceration, large foreign body, and who subsequently developed a traumatic cataract. Following a successful management, the patient's visual acuity improved from 1/60 at presentation to 6/9 at discharge.

Optimal management of the elderly patient with head and neck cancer: Issues regarding surgery, irradiation and chemotherapy.

Head and neck cancer (HNC) represents the sixth most common malignancy and accounts for approximately 6% of new cancer cases annually worldwide. As life expectancy constantly increases, the onset of HNC in patients older than 65 years of age at diagnosis is not rare and up to one fourth of cases occurs in patients older that 70 years at age. Because elderly cancer patients are severely under-represented in clinical trials, there is a clear need to address the particular aspects of this specific patient group, especially in the context of novel multidisciplinary therapeutic approaches. The frailty of elderly patients with HNC is attributed to the high incidence of smoking and alcohol abuse in this malignancy and the presence of substantial cardiovascular, respiratory or metabolic comorbidities. In the current work, I provide an overview of current and emerging treatment approaches, in elderly patients with HNC. In particular, I discuss modern surgical approaches that improve radical excision rates while preserving functionality, the incorporation of modern radiotherapeutic techniques and the introduction of novel chemotherapeutic combinations and molecular targeted agents in an effort to reduce toxicity without compromising efficacy. Finally, there is an urgent need to increase accrual and active participation of elderly patients with HNC in clinical trials, including biomarker evaluation in biopsy specimens towards an individualized therapeutic approach.

Significance and management of positive surgical margins at the time of radical prostatectomy.

Positive surgical margins (PSM) at the time of radical prostatectomy (RP) result in an increased risk of biochemical recurrence (BCR) and secondary treatment. We review current literature with a focus on stratifying the characteristics of the PSM that may define its significance, the impact of modern imaging and surgical approaches in avoidance of PSM, and management strategies when PSM do occur. We performed a review of the available literature to identify factors associated with PSM and their management. PSM have been repeatedly demonstrated to be associated with an increased risk of BCR following RP. The specific characteristics (size, number, location, Gleason score at the margin) of the PSM may influence the risk of recurrence. Novel imaging and surgical approaches are being investigated and may allow for reductions of PSM in the future. The use of adjuvant treatment for a PSM remains controversial and should be decided on an individual basis after a discussion about the risks and benefits. The goal of RP is complete resection of the tumor. PSM are associated with increased risk of BCR and secondary treatments. Of the risk factors associated with BCR after RP, a PSM is directly influenced by surgical technique.

The far-lateral approach for foramen magnum meningiomas

Foramen magnum meningiomas (FMMs) are slow growing, most often intradural and extramedullary tumors that pose significant challenges to the skull base neurosurgeon. The indolent clinical course of FMMs and their insidious onset of symptoms are important factors that contribute to delayed diagnosis and relative large size at the time of presentation. Symptoms are often produced by compression of surrounding structures (such as the medulla oblongata, upper cervical spinal cord, lower cranial nerves, and vertebral artery) within a critically confined space. Since the initial pathological description of a FMM in 1872, various surgical approaches have been described with the aim of achieving radical tumor resection. The surgical treatment of FMMs has evolved considerably over the last 4 decades due to the progress in microsurgical techniques and development of a multitude of skull base approaches. Posterior and posterolateral FMMs can be safely resected via a standard midline suboccipital approach. However, controversy still exits regarding the optimal management of anterior or anterolateral lesions. Independently of technical variations and the degree of bone removal, all modern surgical approaches to the lower clivus and anterior foramen magnum derive from the posterolateral (or far-lateral) craniotomy originally described by Roberto Heros and Bernard George. This paper is a review of the surgical management of FMMs, with emphasis on the far-lateral approach and its variations. Clinical presentation, imaging findings, important neuroanatomical correlations, recurrence rates, and outcomes are discussed.

Современные подходы хирургического лечения мочекаменной болезни

Современные подходы хирургического лечения мочекаменной болезни

A Comparison of the Safety of Lumbar Fusions Performed as Outpatient (24-Hour Discharge) Procedures

Epidemiological studies have shown an increasingly frequent use of outpatient lumbar spine surgery, largely due to the availability of increasingly efficient modern surgical approaches. Lumbar spine fusion, however, has been infrequently reported as an outpatient procedure as conventional surgical approaches generally require extended postoperative observation.