Need For Multiple Procedures Research Articles

Five-Year Results of the Valor II Trial of the Medtronic Valiant Thoracic Stent Graft

Five-Year Results of the Valor II Trial of the Medtronic Valiant Thoracic Stent Graft

Smoking and morphology of calcific deposits affect the outcome of needle aspiration of calcific deposits (NACD) for calcific tendinitis of the rotator cuff

IntroductionAlthough NACD has proven to be an effective minimal invasive treatment for calcific tendinitis of the rotator cuff, little is known about the factors associated with treatment failure or the need for multiple procedures. MethodsPatients with symptomatic calcific tendinitis who were treated by NACD were evaluated in a retrospective cohort study. Demographic details, medical history, sonographic and radiographic findings were collected from patient files. Failure of NACD was defined as the persistence of symptoms after a follow-up of at least six months. NACD procedures performed within six months after a previous NACD procedure were considered repeated procedures. Multivariate logistic regression analysis was used to determine factors associated with treatment failure and multiple procedures. Results431 patients (277 female; mean age 51.4±9.9 years) were included. Smoking (adjusted odds ratio (AOR): 1.7, 95% CI 1.0–2.7, p=0.04) was significantly associated with failure of NACD. Patients with Gärtner and Heyer (GH) type I calcific deposits were more likely to need multiple NACD procedures (AOR: 3.4, 95% CI 1.6–7.5, p<0.01) compared to patients with type III calcific deposits. Partial thickness rotator cuff tears were of no influence on the outcome of NACD or the number of treatments necessary. ConclusionSmoking almost doubled the chance of failure of NACD and the presence of GH type I calcific deposits significantly increased the chance of multiple procedures. Partial thickness rotator cuff tears did not seem to affect the outcome of NACD. Based on the findings in this study, the importance of quitting smoking should be emphasized prior to NACD and partial thickness rotator cuff tears should not be a reason to withhold patients NACD.

Our experience with transcanalicular laser-assisted endoscopic dacryocystorhinostomy (TCLADCR) in patients of chronic dacryocystitis with deviated nasal septum.

The purpose of this study is to study the operative difficulties and success rate of transcanalicular laser-assisted endoscopic dacryocystorhinostomy in patients of chronic dacryocystitis with deviated nasal septum (DNS). A prospective interventional clinical study of 36 consecutive patients suffering from chronic dacryocystitis with nasolacrimal duct obstruction with DNS undergoing primary TCLADCR from March to June 2011 was carried out. Diode laser was used to create a 16-mm(2) ostium which was enlarged to 64 mm(2) using Blakesley's forceps. Success was defined as anatomical patency and absence of symptoms at 12 months of follow-up. Out of the 36 patients, 25 were females with ages 20-72 years, and 19 were left sided. There were 12 high, 12 mid and 12 basal DNS towards the side of surgery, mild to moderate in severity. Intraoperatively there was difficulty in visualising the aiming beam in the nose, tedious manipulation of endoscope and excessive bleeding in 3 patients. Increased bleeding and failures were significantly higher in high DNS (Fisher exact test-2 tailed: 0.0045). The procedure was successful in 94.4 % cases with average ostium size of 21.94 mm(2) at 12 months and no statistically significant difference in success rates between mild and moderate DNS (Fisher exact test-2 tailed: 1.000). Also there was no difference in the complication rate between mild and moderate DNS (Fisher exact test-2 tailed: 0.0841). TCLADCR is an effective procedure in patients with mild to moderate mid and basal DNS and obviates the need for multiple procedures and a cutaneous scar.

Percutaneous nephrolithotomy versus open surgery for treatment of staghorn stones in pediatric patients.

We compare percutaneous nephrolithotomy (PCNL) and open surgery in the treatment of staghorn stones in children. We retrospectively reviewed the electronic records of children who underwent treatment for staghorn stones between September 2000 and August 2013. They were divided between Group 1 (patients who underwent PCNL) and Group 2 (patients who underwent open surgery). We compared stone-free and complications rates, need for multiple procedures, and hospital stay. The study included 41 patients (35 boys and 6 girls), with mean age 7.4 ± 3.1 years (range: 2-15). Of these 41 patients, 26 had unilateral renal stone and 15 had bilateral renal stones. The total number of treated renal units was 56: 28 underwent PCNL and 28 underwent open surgery. The complication rate was comparable for both groups (32% for open surgery vs. 28.6%, p = 0.771). Multiple procedures were more needed in PCNL group (60.7% vs. 32% in open surgery, p = 0.032). The stone-free rate was 71.4% after PCNL and 78.6% after open surgery (p = 0.537). A significant difference was observed in shorter hospital stay after PCNL (5 vs. 8.8 days, p < 0.001). Our study's limitations include its retrospective design and relatively small sample size. For the treatment of staghorn stones in children, PCNL was comparable to open surgery in complication and stone-free rates. PCNL had the advantage of a shorter hospital stay and open surgery showed a decreased need for multiple procedures.

6Long term outcomes after persistent AF ablation: six year data from a high volume UK centre

Introduction: Catheter ablation (CA) for paroxysmal AF is well established but this is not the case for persistent AF (PeAF) where concern still exists about durability and the need for multiple procedures. At present, long-term outcome data for PsAF ablation is lacking, with few studies reporting results for much longer than a single year. We analysed consecutive PeAF ablations performed at our centre from 1/1/2008–31/12/2010 and followed the patients prospectively for 6 years until Jan 2014. Methods: All patient records were analyzed independently by 2 physicians who were not involved in the initial CA procedures. Both arrhythmia recurrence and clinical symptom relief was assessed. Referring hospitals and GPs were contacted to collect missing follow up data and data on any deceased patients. Hospital records of clinic visits were reviewed and at the end of the follow up period all patients were contacted by phone to determine their up-to-date clinical condition. The study was approved by the regional ethics committee. Results: 188 consecutive patients with PeAF (157 male, mean age 57.3 +/−9.7 years, 18% with long standing PeAF) underwent CA by 5 electrophysiologists using 3 different ablation techniques (Carto, NavX and fluoroscopy)during the study period. Pulmonary vein isolation was mandatory with additional additional biatrial ablation as per the preference of the individual operator. Seven (2.3%) procedures were associated with major complications, including 4 tamponades requiring surgical or percutaneous drainage. No patient suffered procedure related death or stroke. Over a median follow up of 45 months (range 4-72), 8 patients died, none from procedure-related causes. During the follow up period, 3 patients suffered a stroke of whom 2 had complete neurological recovery. Of these 3, one had stopped warfarin at their own request because of side effects. Allowing for a 3-month blanking period, 140 (74%) patients experienced recurrence of AF after a single procedure. The median time to first recurrence was 220 (range 91-2023) days. A Kaplan-Meier plot is shown below. 69% of AF recurrences were within the first year following ablation and 89% within 2 years. After a mean of 1.7 procedures (range 1-4) 62% of patients reported considerable clinical improvement or arrhythmia cure with a further 21% reporting at least some improvement. Conclusions: CA for PeAF is safe with low rate of acute and late complications. Over a follow up period of up to 6 years a large majority of patients experience significant improvement in their clinical condition but recurrence after the initial procedure is the norm, rather than the exception, and repeat procedures are commonly required. Although two years' follow up is sufficient to observe approximately 90% of recurrences after CA for PeAF, AF recurrence can occur even after 5 years' remission. ![Graphic][1] [1]: /embed/inline-graphic-1.gif

Treatment of Osteochondral Lesions of the Talus With Marrow Stimulation and Micronized Allograft Cartilage Matrix

Osteochondral lesions of the talus are a common cause of ankle pain. The optimum treatment for these injuries continues to evolve. The article describes an all-arthroscopic technique, which includes debridement, marrow stimulation, and application of a micronized allograft cartilage matrix with fibrin sealant. The procedure avoids potential disadvantages associated with other commonly performed procedures including necessity of arthrotomy or osteotomy, donor-site morbidity, increased cost, and need for multiple procedures. The technique is presented along with promising early clinical results. Level of Evidence: Diagnostic Level 4. See Instructions for Authors for a complete description of levels of evidence.

Removal of endobronchial malignant mass by cryotherapy improved performance status to receive chemotherapy.

Although malignant endobronchial mass (MEM) has poor prognosis, cryotherapy is reportedly a palliative treatment. Clinical data on postcryotherapy MEM patients in a university-affiliated hospital between 2007 and 2011 were evaluated. Survival curve with or without postcryotherapy chemotherapy and performance status (PS) improvement of these subjects were analyzed using the Kaplan-Meier method. There were 59 patients (42 males), with median age of 64 years (range, 51–76, and median performance status of 2 (interquartile range [IQR], 2-3). Postcryotherapy complications included minor bleeding (n = 12) and need for multiple procedures (n = 10), while outcomes were relief of symptoms (n = 51), improved PS (n = 45), and ability to receive chemotherapy (n = 40). The survival of patients with chemotherapy postcryotherapy was longer than that of patients without such chemotherapy (median, 534 versus 106 days; log-rank test, P = 0.007; hazard ratio, 0.25; 95% confidence interval, 0.10–0.69). The survival of patients with PS improvement postcryotherapy was longer than that of patients without PS improvement (median, 406 versus 106 days; log-rank test, P = 0.02; hazard ratio, 0.28; 95% confidence interval, 0.10–0.81). Cryotherapy is a feasible treatment for MEM. With better PS after cryotherapy, further chemotherapy becomes possible for patients to improve survival when MEM caused dyspnea and poor PS.

Lipoenxertia em reconstrução mamária

Background: Breast reconstruction often requires a second surgical procedure to correct visible irregularities of the breast contour. Lipofilling (fat grafting) consists of a surgical technique that improves or corrects such deformities, and serves as an alternative to other conventional techniques that have higher morbidity rates and complexity. In the present study, we aimed to describe our 8-year experience with a fat grafting method for correcting contour deformities of breasts that were previously reconstructed using conventional techniques. Methods: All patients in this study previously underwent mastectomy (total or partial) and some degree of breast reconstruction. The fat was obtained by liposuction using a syringe, and was gently rinsed with a saline solution in a stainless steel sieve, poured into a 60 cc syringe, and grafted after a few minutes. Results: In total, 112 patients underwent surgery between 2005 and 2012. There was one (8.9%) case of total loss of the fat graft, while 22 (19.6%) patients had small palpable nodules. The average graft volume was 100 cc, and multiple procedures were required to achieve the desired volume. Conclusions: Fat grafting is a safe technique with low morbidity rates that demonstrates high surgeon and patient satisfaction levels, despite the need for multiple procedures to achieve good results.

764 Hydrogen Peroxide-Assisted Endoscopic Necrosectomy for Walled-off Pancreatic Necrosis: a Multicenter Pilot Experience

Direct endoscopic necrosectomy (DEN) for walled-off pancreatic necrosis (WOPN) is an accepted approach with rates of success approaching 80%. A technical protocol for DEN has not been standardized. Limitations include inability to remove sufficient necrotic debris from a collection, need for multiple procedures, prolonged procedure time, and complication rates approaching 25%, with bleeding principle among them. Hydrogen peroxide (H2O2) has been used for debridement of tissue within wounds. Through release of nascent oxygen upon contact with tissue, H2O2's effervescent action dislodges necrotic material, debris, and clots.

Treatment of Unicameral Bone Cysts in Pediatric Patients With an Injectable Regenerative Graft

Multiple treatment modalities exist for unicameral bone cysts (UBC), including steroid injection, autologous bone marrow injection, mechanical decompression, intramedullary fixation, curettage, and bone grafting. All have their own potential limitations such as high recurrence rates, cyst persistence, need for multiple procedures, and prolonged immobilization. A minimally invasive regimen consisting of curettage, decompression, and injection of a calcium sulfate-calcium phosphate (CaSO4-CaPO4) composite has been utilized at our institution in an attempt to obtain optimal results for the treatment of UBCs in the pediatric population. We retrospectively evaluated 16 patients with pathologically confirmed UBC who were treated with curettage, decompression, and injection of a calcium sulfate-calcium phosphate composite between April 2006 and August 2010 at a single institution. The average age of the patients at time of surgical intervention was 9.4 years of age (range, 3 to 16 y). Average follow-up was 16 months (range, 6 to 36 mo). Radiographic healing, clinical outcomes, and complications were evaluated. Final follow-up radiographs demonstrated healing in 93.7% (15 of 16) of patients after a single procedure. Complete healing was observed in 14 of 16 patients and partially healed with a defect in 1 of 16 patients. One patient had a persistent cyst but did not wish to receive further treatment. All patients returned to full activities including sports on average at 3.1 months (range, 1 to 6 mo) and were asymptomatic on most recent follow-up. No postoperative complications, including refracture, were observed. Curettage, decompression, and injection of a calcium sulfate-calcium phosphate composite for UBC in the pediatric population demonstrates encouraging results with low recurrence rates and complications compared with conventional methods. Case series, Level of Evidence IV.

Elective Procedures and Anesthesia in Children

The Pediatric Anesthesia NeuroDevelopment Assessment research group at Columbia University Medical Center Department of Anesthesiology has conducted biannual national Symposia since 2008 to evaluate study data and invigorate continued thinking about unresolved issues of pediatric anesthesia neurotoxicities. The third Symposium extended the dialogue between pediatric anesthesiologists and surgeons in panel presentations and discussions by four surgical specialists. This paper reports the prevailing opinions expressed by a pediatric general surgeon, urologist, plastic surgeon and ophthalmologist and explores factors related to delayed operative intervention, need for multiple procedures, and parental concerns.

Remove Airway Ultraflex Stents by Flexible Bronchoscope

IntroductionDespite removal of airway metallic stents by rigid bronchoscope was presented, there are few reports describing such removal by flexible bronchoscope. Methods36 patients who had airway Ultraflex stents removed by flexible bronchoscope from 2002 to 2009 were reviewed. Factors contributing to removal method and complications during and after removal were analyzed by multinomial logistic regression. ResultsAmong 36 patients with stent extraction; 17 stents (47.2%) were removed by a single procedure and 19 (52.8%) by multiple procedures. There was no mortality or severe morbidity during or after stent removal. There were 21 complications after stent removal, including retained stent pieces (n = 9), mucosal tear with bleeding (n = 5), and re-obstruction requiring silicone stent placement (n = 7). Stent indwelling time >10 months (adjusted odds ratio: 9.5; 95% confidence interval: 7.9–11.1, P=0.01), obstructive granulation tissue formation before stent removal (adjusted odds ratio: 5.2; 95% confidence interval: 2.2–8.6, P=0.01), and stent fracture before removal (adjusted odds ratio: 3.5; 95% confidence interval: 1.8–15.4, P=0.04) were independent predictors of the need for multiple procedures for stent removal. Stent indwelling time >10 months (adjusted odds ratio: 4.2; 95% confidence interval: 2.1–8.9, P=0.01), obstructive granulation tissue formation before stent removal (adjusted odds ratio: 16.5; 95% confidence interval, 1.8–49.6, P=0.01), and multiple procedures required for removal (adjusted odds ratio: 6.9; 95% confidence interval, 1.1–43.5, P=0.04) were independent predictors of removal complications. ConclusionsA flexible bronchoscope can be used to remove stents in patients with central airway obstruction and stent-related complications. This procedure should be performed in centers with experienced multidisciplinary teams.

Molecular Diagnosis of Diarrhea: Current Status and Future Potential

Determining the microbiologic etiology of enteric infection remains an elusive goal. Conventional approaches, including culture, microscopy, and antigen-based tests have significant limitations such as limit of detection and the need for multiple procedures. Molecular diagnostics, especially PCR based tests, are rapidly changing research and practice in infectious diseases. Diarrheal disease, with its broad range of potential infectious etiologies, is well suited for multiplex molecular testing. This review highlights examples of currently employed molecular tests, as well as ways in which these tests can be applied in the future. The absence of a gold standard for the microbiologic cause of diarrhea means that the clinical significance of detected organisms may not always be clear. Conventional wisdom is that there should be one main pathogen causing diarrhea, however our thinking is challenged by increased detection of mixed infections. Thus, the successful incorporation of molecular diagnostics for diarrheal disease into practice will require both a careful understanding of the technical aspects and research to define their clinical utility.

Long-term implications of emergency versus elective proximal aortic surgery in patients with Marfan syndrome in the Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions Consortium Registry

Patients with Marfan syndrome with aortic root aneurysms undergo elective aortic root replacement to avoid the life-threatening outcomes of aortic dissection and emergency repair. The long-term implications of failed aortic surveillance leading to acute dissection and emergency repair are poorly defined. We compared the long-term clinical courses of patients with Marfan syndrome who survive emergency versus elective proximal aortic surgery. The Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions Registry is a National Institutes of Health-funded multicenter database and biorepository that enrolls patients with genetically triggered thoracic aortic aneurysms. Of the 635 patients with Marfan syndrome enrolled as of March 2011, 194 had undergone proximal aortic replacement. Patients were grouped according to emergency (n = 47) or elective (n = 147) status at the time of surgery. Patients in the emergency group were more likely to have incomplete proximal aortic resection; 83% of emergency procedures included aortic root replacement, compared with 95% of elective procedures. At long-term follow-up (mean, >6 years), the emergency group had a higher incidence of chronic dissection of the distal aorta and significantly larger diameters in distal aortic segments than elective patients. Patients in the emergency group had undergone more operations (1.31 vs 1.11 procedures/patient; P = .01) and had lower activity scores on a health-related quality of life survey. For patients with Marfan syndrome, failed aortic surveillance and consequent emergency dissection repair have important long-term implications with regard to the status of the distal aorta, need for multiple procedures, and quality of life. These findings emphasize the importance of aortic surveillance and timely elective aortic root aneurysm repair for patients with Marfan syndrome.

Catheter ablation of atrial fibrillation: long-term outcomes

Evaluation of: Weerasooriya R, Khairy P, Litalien J et al. Catheter ablation for arial fibrillation; are results maintained at 5 years of follow-up? J. Am. Coll. Cardiol. 57, 160–166 (2011).Atrial fibrillation is the most common arrhythmia faced in clinical practice with a substantial impact on morbidity, mortality, and heathcare expenditures. Patients with atrial fibrillation in which a rhythm control strategy is desired to improve quality of life have had limited options. The discovery of the role of pulmonary vein triggers has led to the development of catheter ablation techniques that have shown promising short-term success rates. Long-term outcomes were until recently, lacking. These results confirm the inherently recurrent nature of atrial fibrillation and the need for multiple procedures to achieve reasonable long-term successful maintenance of sinus rhythm.

Mo1489 Post-Liver Transplant Anastomotic Strictures: Endoscopic Treatment Is Effective but the Need for Multiple Interventions Has Important Implications on Health Care Costs

Anastomotic bile duct strictures (AS) are a common complication following orthotopic liver transplant (OLT) and have a significant impact on long term outcomes as well as health care costs. While endoscopic treatment is effective, the need for multiple procedures has a significant impact on health care costs. We sought to quantify the health care charges associated with post-OLT endoscopy.

Same Session Bilateral Ureteroscopy is Safe and Efficacious

Bilateral ureteroscopy can be done in 1 sitting, obviating the need for multiple procedures. We analyzed our experience with same session bilateral ureteroscopy to determine its safety and efficacy. In this retrospective study of a 9-year period at Emory University Hospital 1,575 consecutive ureteroscopic procedures were done, of which 95 (6.0%) were done as same session bilateral ureteroscopy, thus constituting our study cohort. Bilateral procedures were performed for urolithiasis in 71 cases, urothelial carcinoma in 9, ureteral stricture in 2 and another indication in 13. Patients were followed at least 1 month postoperatively to evaluate procedural success and assess perioperative complications. Mean age of the 44 male and 40 female patients was 49.8 years. Multiple procedures were done in 9 patients and same session bilateral ureteroscopy was done in 93 of 95 (98%). Intraoperative and postoperative (greater than 1 month) bilateral stone-free rates were 86% and 64%, respectively. The mean change in serum creatinine postoperatively was 0.02 mg/dl (range -0.9 to 1.3). No patient had acute postoperative azotemia. Postoperative complications in 9.7% of patients included pain necessitating an emergency room visit in 4, pyelonephritis/urinary tract infection in 2, and urinary retention, intractable stent pain leading to early removal and urosepsis/death in 1 each. Same session bilateral ureteroscopy is efficacious and safe to evaluate and treat upper tract pathology. While most complications are minor, they may be higher than that typically reported for unilateral ureteroscopic procedures.

Microsurgical Reconstruction: A More Conservative Method of Managing Large Scalp Defects?

Scalp reconstruction is a challenging problem requiring attention to the etiology, size, and condition of the defect to formulate an optimal reconstructive plan. Although many "conservative" options have been described even for large wounds, the use of local flaps or split-thickness skin grafts (STSG) may actually result in the need for multiple procedures, prolonged wound care, increased patient discomfort, and an unsatisfactory aesthetic result. We reviewed 37 patients who had received a total of 38 free flaps for scalp defects >or=100 cm(2) secondary to a broad range of etiologies. There were 24 males and 13 females, with a mean age of 47.4 years (range, 7 to 83 years). The mean scalp defect size was 356.2 cm(2) (range, 130 to 675 cm(2)). More than half the patients had undergone prior local flaps or STSG that had failed (n = 20; 54.1%). Latissimus dorsi muscle or myocutaneous flaps were the most commonly used free flaps in our series. Rectus abdominis muscle, scapular, radial forearm, and omental donor sites were also used. There were a total of 10 complications among 10 patients (27%). Two patients (5.4%) had major complications, and 8 patients (21.6%) had minor complications. Four of our complications (40%) were in patients who had received radiation therapy. We achieved definitive closure using free tissue transfer in 95% of patients who had previous attempts at closure using local options. These results demonstrate that free tissue transfer is a safe and highly efficient reconstructive option to manage large scalp defects under a variety of conditions. In large complex scalp wounds, especially in those patients receiving radiation, microsurgical reconstruction should be the preferred method of management.

Bile duct strictures after liver transplantation: A changing landscape of the Achilles' heel

Bile duct strictures after liver transplantation: A changing landscape of the Achilles' heel

Identification of factors increasing length of stay for patients undergoing lower extremity bypass and lower extremity amputation

After vascular surgery, a large proportion of patients have a decline in disposition from home to nursing rehabilitation facilities. Predictors of this decline include lower extremity revascularizations and amputations, both major and minor (Crouch et al, 2001). Length of stay may increase while a postoperative and postdischarge plan of care is developed, especially for patients undergoing distal bypass because of the need for multiple procedures and treatment of wound infections. Increased baseline illness, consumer demands, managed care, and government reimbursement policies necessitate the efficient management of health care dollars. This presentation will focus on findings of a 4-month institutional review board-approved chart review of available charts of patients discharged after lower extremity amputation or revascularization. Charts were reviewed for variances from the normal procedure-driven Coordinated Care Track. Variances were identified and grouped by patient factors, process factors, or system factors. Patient factors included comorbid conditions, infection, and anticoagulation issues. Process issues included consultation delays, incomplete physician orders, or incomplete implementation of orders. Systems factors included missed therapies, delays in receiving and administering medication, and delays related to postdischarge destination. These findings may be useful to vascular nurses as they develop their own process improvement projects that involve both quality of care and length of stay.