Number Of Operative Procedures Research Articles

前頭側頭開頭術後の開口制限を予防する工夫

Although a number of operative procedures have been already reported to prevent cosmetic and functional complications following fronto-temporal craniotomy, little has been analyzed concerning the limitation of mouth opening due to the atrophy, fibrosis and contracture of the temporal muscle. Our focus was placed on the changes and degrees of maximum postoperative mouth opening day by day following fronto-temporal craniotomy. We evaluated the efficacy of newly modified craniotomy (n=17) compared with the previous conventional one (n=14). Our modified surgical strategy comprises: 1) tailored fascia and pericranium in Z-shaped fashion, 2) gentle manipulation of fascia, pericranium and muscle, and 3) ample humidification of fascia, pericranium and muscle wrapped with soaked saline gauze during operation. In this maneuver, the temporal muscle was firmly anchored to the fascia and pericranium in the original position. Postoperative limited mouth opening of the modified group was quickly (P<0.05) and fully resolved with statistical significance.

The Modified Distal Horizontal Metatarsal Osteotomy for Correction of Bunionette Deformity

Bunionette is a common deformity for which a number of operative procedures have been described. The objective of this study was to evaluate the results of a modified distal horizontal metatarsal osteotomy in the correction of symptomatic bunionette. Metatarsal osteotomies were done in 21 feet in 14 patients (11 females, three males) with an average age of 44 (range 20 to 67) years at the time of operation. The average followup was 32 (range 12 to 52) months. The average Lesser Toe Metatarsophalangeal-Interphalangeal Score of the American Orthopaedic Foot and Ankle Society increased from 42 points (range 24 to 50) preoperatively to 87 points (range 60 to 100) at the last followup. The fifth metatarsophalangeal angle averaged 18 degrees (5 to 38 degrees) preoperatively and 5 degrees (-5 to 26 degrees) at final followup. The 4-5 intermetatarsal angle averaged 14 degrees (10 to 20 degrees) preoperatively and 9 degrees (5 to 12 degrees) at final followup. Hardware was removed from two feet and scheduled for a third foot because of symptomatic skin irritation. The modified distal horizontal metatarsal osteotomy is a stable and reliable method for correction of bunionette. Unsatisfactory results in our patients were related to prominent hardware.

Assessment of postoperative results in anorectal malformations

Surgery for the correction of anorectal malformations (ARM) is performed by almost all pediatric surgeons. A number of operative procedures are practiced. The posterior sagittal anorectoplasty procedure has found wide acceptability and although it provides the most accurate anatomical reconstruction of the neoanorectum and the sphincters, the results are not in keeping with this technical advantage. In addition, there is no uniformity in describing the results of surgery and hence comparative evaluation of different series is difficult. This review describes the various methods that are available for the assessment of postoperative results following surgery for ARM, with a special emphasis on clinical methods keeping in mind the limitations in various parts of the country. Clinical examination and clinical scoring systems hold an important place in the post-operative evaluation of these patients. Imaging modalities are useful in the diagnosis of misplaced bowel and damage to the muscle complex and are necessary before re-do surgery is planned. Objectivity in the evaluation is provided by anorectal manometry combined with electromyography and these corelate well with clinical scoring systems. A consensus is required for uniformity in the methods of assessment.

Arthroscopic-assisted biceps tenodesis for ruptures of the long head of biceps brachii: The cobra procedure.

A number of open procedures have been presented in the literature that described the repair of the ruptured long head of biceps brachii (LHBB). Although arthroscopic biceps tenodesis techniques have been used to address partial tears or subluxation of the biceps, no arthroscopic technique to assist in the treatment of complete retracted ruptures of the LHBB has been described. This article describes an arthroscopic-assisted biceps tenodesis, using interference screw fixation, in the treatment of acute or chronic LHBB ruptures. An arthroscopic-assisted biceps tenodesis with interference screw fixation provides an alternative to open LHBB tenodesis. The ability to tenodese the retracted LHBB arthroscopically is a technologic advance that could reduce morbidity in comparison to open tenodesis, thus resulting in a better functional outcome.

What influences the functional outcome of children at 6 months post-burn?

The contribution of demographic, injury, pre-morbid, and parent factors to a child’s functional outcome at 6 months post-burn injury was examined. Sixty-eight children, aged 5–14 years with percent total body surface area (%TBSA) burns ranging from <1 to 35%, and their primary caregivers participated in the study. It was expected that pre-morbid and parent factors but not injury factors would have a significant impact on the functional outcome of children at 6 months post-burn. Injury factors included the percent of total body surface area burned, number of operative procedures, and source of the burn (i.e. flame burn, scald burn). Pre-morbid child factors included the presence or absence of behaviour problems, psychological or psychiatric problems, learning difficulty or developmental delay. Parent factors included anxiety, depression, coping processes, and social support. Whilst investigating the contribution of these factors to functional outcome, the effect of demographic factors (i.e. age, gender, family socioeconomic status, and the number of previous hospitalizations) was controlled for and investigated. Analyses included two hierarchical multiple regression analyses that supported the expected results. R was significantly different from zero at the end of each step in both hierarchical regression analyses, indicating that each group of factors added significantly to the fit of the model. After step 4 in the final regression model with all independent variables in the equation, R=0.85, F(18,49)=6.89, P<0.001.

Gastroschisis: Small hole, big cost

Background/Purpose: This study was designed to assess the outcome and financial costs incurred for the treatment of gastroschisis. Methods: A retrospective analysis was conducted of all patients with gastroschisis at a single institution over the past decade (n = 69). Hospital costs were determined and standardized to December 2001 dollars. Results: Of the 69 patients, average gestational age at delivery was 35.9 weeks. Thirty-six patients had a primary fascial closure; 33 had a silo placed. The mean time to first feeding was 22 days and full feeding, 33 days. Average length of stay was 47 days. There were 3 deaths (2 shortly after birth, and one 131 days later owing to sepsis). The average cost of hospitalization and physician fees for patients with gastroschisis was $123,200. Using multivariate regression analysis, significant variables (P <.05) associated with cost of hospitalization were number of operative procedures, ventilatory days, male gender, and length of stay. Room expenses (43%), physician fees (15%), respiratory and pulmonary care (10%), and supply and devices (10%) made up the majority of costs. Conclusions: Cost of care associated with treatment for gastroschisis is high. Strategies designed to reduce cost must limit gastrointestinal, respiratory, and operative complications and reduce length of stay. J Pediatr Surg 37:1669-1672. Copyright 2002, Elsevier Science (USA). All rights Reserved.

The rheumatoid wrist. Pathobiomechanics and therapy

A stable and pain-free wrist is a prerequisite for normal hand function. Since the wrist joint is involved early in rheumatoid disease and progress is rapid, operative treatment is of major importance. It is indicated not only for treatment of established osseous changes with instability, deformation, and extensor tendon ruptures but for early treatment of drug-resistant synovitis and monarthritis of the wrist.A considerable number of operative procedures is available: arthroscopic or open synovectomy of the radio- and midcarpal as well as the distal radioulnar joint, possibly with resection of the ulna head, partial arthrodeses, complete arthrodeses,and arthroplasty. When choosing the procedure, type and stage of wrist changes as well as the pathobiomechanic situation have to be considered. The individual course of the disease and patient requirements have to be taken into account.Thus, for long periods of time a pain-free stable wrist can be preserved, albeit sometimes with only limited but functional mobility.

Increased incidence of heater-related burn injury during a power crisis.

Recent power shortages in California resulted in rolling blackouts and increased utility prices. Residents turned to alternative heating devices, such as space heaters, to decrease utility bills. Our hypothesis is that the incidence of heater-related injuries increased owing to the use of alternative heating methods during the power crisis. Retrospective case-series database and medical record review of all burn admissions for the 4 months of November through February for the period 1998-2002. Regional pediatric and adult burn unit in northern California. Patients admitted during the study interval with burn injury. Parameters recorded included patient demographics, cause of burn, total body surface area burn, number of operative procedures, and hospital length of stay during each of the 4 months in the interval. A total of 512 patients were admitted during all 4-month intervals. During the power crisis there were significant increases in the number of hospital admissions (151 in 2000-2001 vs 117 in 1998-1999, 124 in 1999-2000, and 152 in 2001-2002) and heater-related burn admissions (36 in 2000-2001 vs 25 in 1998-1999, 26 in 1999-2000, and 29 in 2001-2002). The percentage total body surface area burn (mean +/- SEM, 24.0% +/- 4.6% in 2000-2001 vs 16.5% in 1998-1999, 12.3% in 1999-2000, and 12.0% in 2001-2002), hospital length of stay (15.0 days in 2000-2001 vs 9.9 days in 1998-1999, 12.3 days in 1999-2000, and 7.0 days 2001-2002), and the number of operations (55 in 2000-2001 vs 7 in 1998-1999, 18 in 1999-2000, and 19 in 2001-2002) also increased during the crisis. The number of heater-related burn admissions, as well as their magnitude, increased during the energy crisis, resulting in increased resource use and health care costs. The economic stresses of the power shortage had societal costs that extended far beyond the price of electricity.

Effects of delayed wound excision and grafting in severely burned children.

Advances in burn treatment including early excision of the wound have increased survival in patients treated at specialized burn centers. We hypothesized that the patients with delayed wound excision and grafting would experience deleterious outcomes. From 1995 to 1999, 157 children with acute burns covering 40% or more of total body surface area and having more than 10% of full-thickness burns were admitted to our institution within 2 weeks of injury. Among them, 86, 42, and 29 patients underwent first operation on days 0 to 2, days 3 to 6, and days 7 to 14 after burn, respectively. Outcomes observed were mortality, number of operative procedures, length of hospitalization, blood transfused, incidence of wound bacterial and fungal contamination, invasive wound infection, and sepsis. Demographic data for the groups showed no differences in sex or total body surface area burned. Mortality and number of operative procedures and blood transfusions were not different between groups. Hospitalizations were longer in the delayed groups, which was associated with a higher incidence of significant wound contamination (P =.008). Invasive wound infection also increased significantly with delay of excision (P<.001). An increased incidence of sepsis was seen in patients with delayed wound excision and grafting (P =.04). Delays in excision were associated with longer hospitalization and delayed wound closure, as well as increased rates of invasive wound infection and sepsis. Our data indicate that early excision within 48 hours is optimal for pediatric patients with massive burns.

Management of infected bulk allografts with antibiotic-impregnated polymethylmethacrylate spacers.

Twenty-seven patients developed infection following bulk allograft transplantation and were treated with resection of the allograft, placement of an antibiotic-impregnated polymethylmethacrylate (PMMA) spacer, and intravenous antibiotics. Overall, the infection was eradicated in 14 (52%) of 27 patients. Of the 11 patients who did not undergo allograft reimplantation, 5 underwent amputations for persistent infection in the presence of the spacer and 4 had a retained spacer at most recent follow-up. No significant correlation was noted between successful eradication of the infection and age, sex, diagnosis, adjuvant therapy, acute or chronic infection, number of operative procedures, type of allograft procedure, duration of antibiotics, or type of organism. Although deep infection of allograft transplantations continues to result in a high rate of failure, this method of management results in successful limb salvage in almost half of the patients.

Educational attainments in early adolescence of infants who required major neonatal surgery

Purpose: The aim of this study was to assess long-term educational attainment in adolescence of former infants who required major neonatal surgery. Methods: The study is an extension of a prospective longitudinal study begun in 1983 on 30 full-term newborns requiring major neonatal surgery, a matched healthy control group, and full-term infants requiring neonatal intensive care for medical reasons. Educational attainment levels were obtained from the results of compulsory national curriculum examinations taken at age 11 years in 3 core academic subjects, English, Mathematics, and Science and teachers' assessments of current academic performance. Additionally, follow-up data on health were obtained from family general practitioners and parents. Results: Seventy percent of the original surgical group, 48% of the original control group, and 77% of the original medical group underwent follow-up. The participants were aged between 11 and 13 years. After adjustment for social factors (gender, social group, and mother's age), the surgical group was significantly behind on all measures of educational attainment (English, P <.0005; Mathematics, P <.02; Science, P <.0005; academic performance, P =.004), compared with the control group and medical group who did not differ from each other. Independent predictors of outcome were mechanical ventilation for ≥4 days in the neonatal period and behavior problems at 3 years. At 12 months of age, independent predictors of cognitive functioning were length of hospitalization and, at 3 years of age, the number of operative procedures. Mechanical ventilation was not significantly associated with cognitive functioning at previous stages of the study. Conclusions: These results show that, in early adolescence, children who required major neonatal surgery were performing less well academically compared with their peers. This information can be used to increase awareness of the difficulties these children may experience during childhood so that intervention can be directed appropriately, thereby lessening the risk of later educational problems. J Pediatr Surg 36:858-862. Copyright © 2001 by W.B. Saunders Company.

The Increasing Need for Nonoperative Treatment of Patients With Osteoarthritis

Osteoarthritis affects more patients than almost any other musculoskeletal disorder. The number of patients suffering joint pain and stiffness as a result of this disease will increase rapidly in the next decade. Although operative treatments of patients with osteoarthritis will continue to improve and the number of operative procedures will increase slightly in the next decade, only a small fraction of the patients with osteoarthritis will require operative procedures. The most pressing healthcare need for the majority of patients with osteoarthritis is nonoperative care that helps relieve symptoms and improve function, and in some instances slows progression. In rare instances, the symptoms of osteoarthritis improve spontaneously, but most patients need nonoperative care for decades. Orthopaedists need to improve their ability to provide nonoperative care for patients with osteoarthritis. They should be skilled in the early diagnosis of osteoarthritis and in the use of current common nonoperative treatments including patient education, activity modification, shoe modifications, braces, oral analgesics, oral nonsteroidal antiinflammatory medications, oral dietary supplements, and intraarticular injections. Furthermore, orthopaedists should be prepared to incorporate new nonoperative treatments for patients with osteoarthritis into their practice.

Less invasive anterior fusion of the cervical spine

SummaryTrauma, degenerative and inflammatory diseases, or tumours may destabilise and deform the cervical spine, causing compression of the spinal cord and/or the nerve roots. The goals of surgical therapy are decompression of the neurostructures and restoration of the physiological alignment, along with stabilisation by fusion and fixation of the affected vertebrae. ‘Minimally invasive’ defines an effective surgical treatment with the least morbidity for the patient. The combined use of computed tomography (CT) and MRI, microsurgical techniques, intra-operative fluoroscopy and devices for internal fixation (plates and screws) has significantly improved the outcome. Nowadays bone graft substitutes, endoscopy and image-guided navigation are being introduced for clinical use, in order to reduce the surgical morbidity even further. Benefits of this evolution are: surgical procedures tailored for different pathologies; early mobilisation and rehabilitation, especially of elderly patients. Disadvantages are: a rapidly increasing number of operative procedures with a demanding learning curve, which have to be performed at specially qualified centres; and increasing sophistication (as a potential source of error) of the surgical equipment. A more balanced cooperation between industry and clinicians, along with an ethical agreement on how much surgery should be done, has become mandatory.

Anatomy of the retroperitoneum from the viewpoint of minimally invasive surgery

Today a large number of operative procedures on retroperitoneal organs can be performed using minimally invasive techniques. The retroperitoneal space can be reached laparoscopically through the peritoneal cavity or by the direct retroperitoneoscopic approach. The correct anatomical placement of the first trocar is of particular importance in procedures with the patient in lateral decubitus position in order to avoid injuries. The overview is worse than in conventional surgery because of the magnifying effect of the laparoscope, which is, furthermore, positioned very close to the operative field. It is therefore of great importance for the surgeon to use anatomical structures for orientation. The decisive anatomical aspects and landmarks in different minimally invasive operations on retroperitoneal organs are outlined.

Single-stage revascularization and free flap coverage in the treatment of ischemic lower limb lesions

Old age, diabetes and atherosclerotic disease all have been considered to be relative contraindications for microsurgery. As such, gangrenous lesions of the lower limb traditionally resulted in staged amputations. A more aggressive approach, combining revascularization and free tissue transfer, allowed us to limit the level of amputation and to start early ambulation and rehabilitation, without the need for major orthotic help. Performing the vascular procedure, debridement, and free tissue transfer in one single intervention greatly reduces the number of operative procedures without substantial increase in operative time. Twenty consecutive patients underwent a combined free flap and revascularization procedure, two patients died perioperatively. One free flap was lost and needed replacement. All surviving patients were ambulating postoperatively.

Endoscopic approach to the anterior skull base

Today, endoscopic endonasal operations have become daily routine in ENT-surgery, particularly endonasal surgery in cases of chronic polyposis of the paranasal sinuses. Younger ENT surgeons become familiarized with these endonasal techniques during their training. On the other hand, the number of operative procedures on the paranasal sinuses via the possible external approaches is decreasing because a growing number of diseases can be treated by modern endonasal techniques. Modern suction-irrigation endoscopes, combined with a high performance endocamera (chip camera) provide a clear vision in the operative field. This allows the surgeon to work quite safely inside the nose and the paranasal sinuses, as well as near to the posterior part of the orbit and the frontal skull base. Working under videoendoscopic control is especially safer for the less experienced surgeon because supervision of every step of the operation is easy to achieve. Many patients with chronic polyosis of the sinuses are resistant to conservative drug treatment and depending on the amount of polyposis, are typically treated by endonasal operations, such as partial ethmoidectomy or complete sphenoethmoidectomy. However, during the last few years more conditions involving the frontal skull base or the paranasal sinuses are treated by endoscopic approaches. 1-4 We have developed a new concept for the treatment of conditions such as cerebrospinal fluid (CSF) leakage, fractures of the skull base and the orbit, etc., primarily using endoscopic minimally invasive operative techniques.

Polypropylene mesh closure of the complicated abdominal wound

Background: Closure of the abdominal wall in the face of fascial necrosis or massive intestinal edema remains a difficult problem with frequent complications. Prior studies have addressed both the utility and the pitfalls of placing polypropylene mesh in this setting. Methods: We performed a retrospective evaluation of our experience with polypropylene mesh in traumatic and nontraumatic difficult abdominal closures. Timing of mesh placement and removal relative to the initial operation were recorded, as were abdominal complications, number of operative procedures, and type of ultimate abdominal closure. Results: Between 1988 and 1993, polypropylene mesh was placed in 26 critically ill or injured patients requiring celiotomy, of whom 23 survived more than 3 weeks. Ultimate wound management was delayed mesh removal and primary closure (17%), myocutaneous flap coverage over mesh (4%), split-thickness skin grafting to the granulating wound (35%), or closure by secondary intention over mesh (43%). Split-thickness skin grafting and closure by secondary intention resulted in enterocutaneous fistulas in 50% and 40% of cases, respectively. Full-thickness closure with or without mesh removal resulted in no fistulas. Conclusion: Mesh provided adequate fascial closure, even with gross wound contamination. Coverage of polypropylene mesh by secondary intention or split-thickness skin grafting resulted in unacceptably high rates of fistulous complications, and this procedure should be replaced by either mesh removal or full-thickness coverage.

Clinical Significance of Preoperative Nutritional Status in Pediatric Surgical Patients

This prospective study was undertaken to correlate the preoperative nutritional status in pediatric surgical patients with postoperative morbidity. The prevalence of protein-calorie malnutrition in our patients is also evaluated. Sixty-two consecutive pediatric surgical patients were admitted elective to King Khalid University Hospital for different reasons. Seventy-four major and intermediate surgical procedures were carried out. The patients were assessed nutritionally on the day of admission by using anthropometric and biochemical methods. Patients were monitored for complications during their hospital course. Eighty percent of patients have one or more abnormal values suggestive of protein-calorie malnutrition. Six patients had 8.1% complication rate. Five of them showed moderate to severe malnutrition. The correlation between malnutrition and postoperative morbidity was evident but was not of clinical or statistical significance. And the predictive value of nutritional variables in predicting postoperative complications were difficult to assess in this study but they generally were of little help.

Status of surgical dermatology in the hospital and general practice

Dermatosurgery has been gaining in importance in recent years. In departments of dermatology German-speaking countries the total number of operations increased by 58% from 1984 to 1991. The increase in the number of operations of moderate and extreme severity was especially marked. Out-patient dermatosurgery was also performed mainly by dermatologists as opposed to other specialties. From 1988 to 1992 dermatologists in private practice recorded an increase of 40.6% in the number of operative procedures they performed. The importance of dermatosurgery in hospital and private practice can be expected to continue increasing in the future; dermatologists must therefore prepare themselves for the present and future challenges inherent in surgery of the skin.

An Analysis of Factors Contributing to the Development of Total Parenteral Nutrition‐Induced Cholestasis

The risk of developmental of total parenteral nutrition (TPN)-associated cholestatic jaundice in neonates receiving intravenous hyperalimentation is high. Numerous factors have been cited as contributing to TPN cholestasis; however, the exact etiology remains obscure. This retrospective study was undertaken in order to identify any factors which might contribute to this syndrome. The hospital records of 172 neonates requiring TPN for a minimum of 1 week were reviewed. In addition, a subgroup of 32 infants requiring TPN for a minimum of 7 weeks was also examined. Cholestasis was defined as a direct serum bilirubin greater than 2.0 mg/dl during the course of TPN therapy. Significant factors for the development of cholestasis in both groups (n = 172, n = 32) included: number of operations (2.56 vs. 1.08, p = 0.0000), the number of days the patients received antibiotics (40.3 vs 12.9, p = 0.0000), and delayed start of enteral feedings (33.8 vs 14.1, p = 0.0000). Fifteen of the 32 patients who received TPN for at least 7 weeks did not develop cholestasis. In this subgroup (n = 32), there were no differences in birth weight, gestational age, days from birth to the start of TPN, or respiratory distress between those who developed cholestasis and those who remained anicteric. In contrast, there were significant differences between the cholestasis and noncholestasis groups in number of operations (13 vs 6, p = 0.0407), and days until enteral feedings were started (33.1 vs 18.9, p = 0.0289). This study suggests that the factor(s) contributing to the development of TPN-associated cholestasis are likely multifactorial. There appears to be a direct correlation between increasing severity of cholestatic jaundice and duration of TPN. This review does add a new parameter to the various causative factors suggested, namely the number of operative procedures. This new variable could be related to the stress of surgery itself or to the repeated administration of anesthetic agents.