Postoperative Assessment Of Patients Research Articles

Role of tomographic imaging in preoperative planning and postoperative assessment in cardiovascular surgery

Cardiovascular surgeries have become progressively more sophisticated and complicated, due to factors such as the increasingly advanced age of patients, significant comorbidities, and increasing surgical complexity—minimally invasive procedures, reoperations and...

Role of multi-slice CT angiography in the evaluation of pulmonary venous anomalies

Purpose and aimTo assess the role of MSCT angiography in evaluation of extra-cardiac vascular abnormalities in pulmonary venous anomalies and compare it with echocardiography. Materials and methodsThis study included 26 patients with an age range of 15 days–25years. All of these patients underwent MSCT angiography and echocardiography. Only 10 patients underwent cardiac catheterization. ResultsOur initial experience showed that MSCT is capable of complementing echocardiography and replacing diagnostic cardiac catheterization for anatomical delineation if performed with an optimum technique.MSCT angiography proved to be a worthy primary investigation tool in patients whom ECHO has been able to clearly identify the intracardiac anatomy, but not the extra-cardiac vascular anatomy. ConclusionMDCT correctly depicted the TAPVR (Total anomalous pulmonary venous return) and PAPVR (Partial anomalous pulmonary venous return) types of pulmonary venous anomalies with sensitivity 100%, and specificity 100%. The specificity of echocardiography was 50% for both findings. Inspite of the risk of ionizing radiation and contrast medium injection the adoption of our minimal invasive, low radiation, non-ECG gated protocol greatly reduces the time, radiation dose, and contrast medium volume needed to perform an optimum CT angiographic technique. Thus, paving a clear road map for pre and post operative assessment of patients with pulmonary venous anomalies.

Esophageal Disorders Not Yet Addressed by High-resolution Manometry

TO THE EDITOR: We greatly appreciate the insight provided by Wang et al1 regarding their recent review of the esophageal disorders not assessed by the Chicago classification of motility disorders of the esophagus. This is an important issue as many people still fail to understand that the Chicago classification was designed to describe and categorize distal esophageal motor disorders focused on dysphagia and was not meant to be a global classification across the entire spectrum of esophageal disorders. All patients undergoing manometry will have a Chicago classification diagnosis, however, there may be other motor abnormalities of the upper esophageal sphincter, proximal esophagus or esophagogastric junction and proximal stomach that may be important in the patients presenting complaints and these need to be described separately from the Chicago classification diagnosis. To utilize the Chicago classification, one has to follow specific rules and calculate specific metrics in a predefined order and the analysis is confined to an assessment during 10 supine 5 mL water swallows.2 We experienced that changing position elicited a change in diagnosis in about 10% of studies, and that provocative bolus challenges modified the diagnoses by increasing the number of patients classified with an esophagogastric junction outflow obstruction.3 However, this did require utilization of different standard values and thresholds to allow for a refined characterization and represents one aspect where the Chicago classification diagnosis can be complemented. Similarly, the Chicago classification is also restricted to assessing patients before definitive treatment and although the Chicago classification can be modified to assess patients after antireflux procedures, bariatric surgery or treatments focused on disrupting the lower esophageal sphincter in achalasia; there are no reference ranges to define what is normal in the post-operative state. Nevertheless, the Chicago classification metrics, such as the integrated relaxation pressure and intrabolus pressure pattern, can help one discern whether there is an outflow obstruction after intervention and continued abnormal peristalsis.4,5 Thus, it is likely that the metrics described in the Chicago classification can be utilized, or modified, to help define disorders outside of those that are focused on distal esophageal motor function. Moving forward, the next steps in the evolution of high resolution manometry and esophageal pressure topography should focus on describing specific disease related processes highlighted in the review published by Wang et al,1 such as disorders related to gastroesophageal reflux, upper esophageal sphincter and proximal esophageal dysfunction in dysphagia, post-prandial complaints of regurgitation/possible rumination syndrome and postoperative assessment of symptomatic patients. This will require rigorous evaluation with careful description of normal thresholds and will require outcome data. This is no easy task as the evolution of the Chicago classification to its final version took almost 5 years and it is still being refined. Initial steps in the process of categorizing esophageal motor dysfunction as it relates to gastroesophageal reflux, are currently underway. Hoshino et al6 have described new metrics of defining esophagogastric junction function as an antireflux barrier using modifications of the Chicago classification metrics and correlates of ineffective motility have been defined for esophageal pressure topography.7 Additionally, more emphasis on post-prandial assessments and provocative meals are also being studied to help elucidate mechanism of reflux that may be contributing to the patients underlying symptoms and there are new definitions for the assessment of transient lower esophageal sphincter relaxation using high resolution manometry.8,9 These are promising advances, however, we are only in the preliminary stages and although many have described motor abnormalities in the upper sphincter and post-prandial state, there is a paucity of reference data and consensus regarding terminology and definitions to help define new classifications for these disorders. Thus, the Chicago classification should be utilized as it was intended and designed with the idea that it can be complemented by an assessment of motor function that extends beyond the distal esophagus and 10 supine water swallows. We look forward to future work that may lead to a parallel classification scheme for other disorders not covered by the Chicago classification and we look forward to another great city taking over where Chicago left off.

Tongue base suspension using a repose bone screw system in the treatment of obstructive sleep apnea

EnAbstract Objectives The aim of this study was to evaluate the tongue base suspension suture technique using a repose bone screw system with respect to efficiency in relieving obstructive sleep apnea, safety, and postoperative morbidity. Study design This was a prospective study carried out on 10 patients with a complaint of moderate or severe obstructive sleep apnea because of retrolingual hypopharyngeal obstruction. Methods Demographic data were determined and preoperative investigations (flexible nasopharyngoscopy, polysomnography, and lateral cephalometry) were carried out; in addition, operative technique and postoperative assessment of patients’ complaints and postoperative data of polysomnography and lateral cephalometry were carried out. Results Improvement in the main complaints of patients, a significant reduction in the mean apnea hypopnea index in postoperative polysomnography, and an increase in the mean posterior airway space at the level of the tongue base in postoperative lateral cephalometry were recorded. Conclusion The tongue base suspension technique using a repose bone screw system is an easy and efficient procedure for the treatment of retrolingual obstruction, with minimal postoperative morbidity.

Selective amygdalohippocampectomy versus standard temporal lobectomy in patients with mesial temporal lobe epilepsy and unilateral hippocampal sclerosis

Several studies have demonstrated the positive effect of resective epilepsy surgery in drug-resistant temporal lobe epilepsy (TLE). However, it is still a matter of debate whether selective amygdalohippocampectomy (SAH) or standard temporal lobectomy (STL) are the most effective approaches concerning seizure outcome, quality of life and memory. In each of the two centers participating in this study either SAH or STL was the neurosurgical standard procedure irrespective of contextual aspects. Thus, with this postoperative assessment of resected patients we sought to avoid any selection bias that usually impaired comparative trials of both surgical approaches. We finally identified and studied 95 adult patients who had undergone either SAH (n=46) or STL (n=49) between 1999 and 2009 and fulfilled the inclusion criteria, namely drug-resistant unilateral mesial TLE with hippocampal sclerosis without any further structural lesions. We assessed the postoperative seizure outcome according to the ILAE criteria and postoperative quality of life by means of standardized questionnaires. Finally, we compared postoperative neuropsychological performance in 60 completely seizure-free patients (n=27 after SAH, n=33 after STL) prior to, one year after surgery and at a long-term follow-up with a mean of seven years. 78.2% of SAH and 85.7% of STL were seizure-free at the last observation. Quality of life had improved in 95.6% of the SAH patients and 89.8% of the STL patients. These differences were not statistically significant. Left-sided TLE patients had a significantly worse verbal memory outcome irrespective of the surgical method. However, SAH patients had a significantly better outcome concerning visual encoding, verbal and visual short-term memory and visual working memory. In this study, seizure outcome and quality of life did not differ depending on the surgical approach. However, a more selective resection led to better neuropsychological performances.

Spinal cord decompression: Is country of surgery a predictor of outcome?

Dear Sir, We read the important paper of Shamim et al.[5] about the question as to whether patients with spinal cord injury (SCI) benefit from spinal stabilization. We believe that the decision to perform spine surgery on patents with SCI should not be made only based on duration of hospital stay, economic issues, and neurological outcome.[4] However, we would emphasize the apparent advantage of non-operative management of SCI patients in developing countries. In Zahedan, a city located in a poor socioeconomic province of Iran, we managed 108 patients with SCI during a 12-year period from 1994 to 2005. Of these patients, 50 were followed for more than 12 months. Assessment of outcome of these patients not only confirmed superiority of non-surgical management in patients with complete SCI in terms of cost and duration of hospitalization, but also, surprisingly, showed that the neurological outcome of patients with incomplete SCI in the non-surgical group was not different from that of the surgical group. Length of stay in surgery group of SCI patients was 11.1 ± 5.46 days, which was significantly longer than 5.8 ± 0.96 days in non-surgical patients (P = 0.017). All groups of patients with incomplete SCI including those treated non-operatively, patients had early operation or cases underwent late surgery, had significant and similar improvement, when compared to the preoperative examination (P = 0.02), with no difference among these three groups.[2,3] Our results differ from those of the meta-analysis of La Rosa et al.,[1] which concluded neurological improvement after early decompression in incomplete SCI patients compared to late decompression or non-surgical management. In this meta-analysis, 26 studies were evaluated, all of which had been performed in developed countries, with no study from developing countries. The results of this meta-analysis is also different from the study performed by Shamim et al.,[5] which may indicate different outcome of spinal cord decompression in developed and developing countries. Despite the limitations of the study by Shamim et al.,[5] such as heterogeneous cohort of patients, inconsistent prednisolone prescription, late decompression in considerable number of patients, different surgical procedures, and lack of post-operative neurologic assessment of patients, it can be hypothesized that the country where surgery is performed (developing vs. developed countries) may have an effect on the outcome of SCI patients. Thus, results of some reports on favorable outcome of patients undergoing spinal decompression/stabilization from developed countries should be interpreted carefully if they are to be used in developing countries since many pre-, intra- and post-operative factors may contribute to the outcome of these patients. Further studies from developing countries should be performed to provide better guidance for spine surgeons in these countries to decide whether an SCI patient is likely to benefit from spinal decompression/stabilization or not.

The Provision of Weekend Physiotherapy Services in Tertiary-Care Hospitals in Canada

To describe the provision of weekend physiotherapy (PT) services in tertiary-care hospitals in Canada. A prospective cross-sectional survey was conducted across tertiary-care hospitals, defined as those with university affiliation and at least one intensive care unit (ICU). Data were collected via telephone-administered questionnaires addressing hospital demographics, weekend staffing, workload, and weekend referral criteria. A response rate of 84% (n=36) was obtained. Of facilities providing weekend PT services (97%), 35 (100%) provided care on Saturdays, 32 (91%) on Sundays, and 33 (94%) on statutory holidays. Weekend services were staffed using permanent full-time (n=35; 100%) or part-time (n=28; 80%) in-patient staff or outsourced staff (n=1; 3%). The number of physiotherapists available on the weekend was smaller than the number available during the week (p<0.001). Common weekend referral criteria included cardiorespiratory problems (n=35; 100%), postoperative assessment of patients at risk for deterioration (n=32; 91%), and patients scheduled for discharge pending PT assessment (n=30; 86%). Both the scope and the number of staff available to provide PT services were less on the weekend than during the week. Despite the use of common criteria for weekend referral, variability in this service exists. Knowledge pertaining to current weekend PT services provides opportunities for harmonization of service delivery.

The Provision of Weekend Physiotherapy Services in Tertiary-Care Hospitals in Canada

Purpose: To describe the provision of weekend physiotherapy (PT) services in tertiary-care hospitals in Canada. Methods: A prospective cross-sectional survey was conducted across tertiary-care hospitals, defined as those with university affiliation and at least one intensive care unit (ICU). Data were collected via telephone-administered questionnaires addressing hospital demographics, weekend staffing, workload, and weekend referral criteria. Results: A response rate of 84% (n=36) was obtained. Of facilities providing weekend PT services (97%), 35 (100%) provided care on Saturdays, 32 (91%) on Sundays, and 33 (94%) on statutory holidays. Weekend services were staffed using permanent full-time (n=35; 100%) or part-time (n=28; 80%) in-patient staff or outsourced staff (n=1; 3%). The number of physiotherapists available on the weekend was smaller than the number available during the week (p<0.001). Common weekend referral criteria included cardiorespiratory problems (n=35; 100%), postoperative assessment of patients at risk for deterioration (n=32; 91%), and patients scheduled for discharge pending PT assessment (n=30; 86%). Conclusion: Both the scope and the number of staff available to provide PT services were less on the weekend than during the week. Despite the use of common criteria for weekend referral, variability in this service exists. Knowledge pertaining to current weekend PT services provides opportunities for harmonization of service delivery.

Development of a nursing practice guideline for pre and post-operative care of gastric cancer patients.

ObjectivesThe aim of this study was to develop nursing practice guidelines and algorithms for the pre- and postoperative care of gastric cancer patients.MethodsThe guidelines and algorithms were developed based on a literature review and subject-matter experts' knowledge. The usefulness and applicability of the developed guidelines and algorithms were evaluated by the expert group.ResultsThe guidelines comprised 64 recommendations and algorithms for admission care, preoperative care on the day before the operation, preoperative care on the operation day, immediate postoperative assessment, postoperative care, and discharge care of gastric cancer patients. After appropriate evaluation, the experts declared the guidelines to be both useful and applicable.ConclusionsThe guidelines developed in this study can be used for patient care and for training nursing students and novice nurses. In addition, these guidelines can be integrated into the electronic nursing record system for clinical decision support in the future. This will improve the quality of clinical nursing and the expertise of nurses.

Pre and post-operative assessment of patients with a stoma

This article aims to increase healthcare professionals' understanding of the pre and post-operative care of patients undergoing stoma-forming surgery. Areas covered include pre-operative information given to patients, post-operative nursing care and psychological considerations that should be taken into account for any patient undergoing stoma-forming surgery.

Volumetría y electroencefalografía digital en pacientes con epilepsia del lóbulo temporal medial farmacorresistente sometidos a cirugía

To assess the value of volumetric measurement by means of magnetic resonance imaging (MRI) and interictal electroencephalogram (EEG) in pre- and post-operative assessment of patients with medication-resistant medial temporal lobe epilepsy (MTLE) who were submitted to surgery. We evaluated 12 volumetric studies carried out using MRI and 24 digital EEG records for six patients suffering from complex partial seizures that were resistant to medical treatment and had their origin in the temporal lobe. A volumetric analysis was performed using MRI to study the epileptogenic region and the frequencies at which interictal epileptiform discharges (IED/minute) appeared before, at six months and at one year after surgery were calculated; a correlation was observed between the volumetric analysis and the irritative and epileptogenic region. The volumes of both the ipso and contralateral hippocampuses were smaller in comparison to the increased frequency of the IED in the mesial regions. The inferior temporal lobes and the parahippocampal cortex have reduced volumes ipsolateral to the epileptogenic region. At six months after performing the temporal lobectomy, the IED frequency decreased with respect to the pre-operative IED. A negative correlation was found between the resected volume of the parahippocampal cortex and the inferior temporal lobe, and the post-operative IED frequency at one year. In patients with medication resistant MTLE the volumes of other structures in the medial temporal lobe are diminished, in addition to the hippocampus, and they are seen to have a smaller volume on the side that is ipsolateral to the epileptogenic region. There is a relation between the volume of the resected hippocampus and the post-operative IED frequency in patients with MTLE who successfully underwent a temporal lobectomy. Volumetric analysis of the epileptogenic lesion using MRI provides localising information that is valuable in the pre-operative assessment of patients with medication resistant MTLE who are submitted to surgery.

Prospective Study Examining the Impact of Multichannel Intraluminal Impedance on Antireflux Surgery

Reflux monitoring using combined multichannel intraluminal impedance (MII) and pH-metry increases the sensitivity for identifying gastroesophageal reflux episodes. The likelihood of a positive symptom index (SI) for patients with reflux disease (gastroesophageal reflux disease [GERD] or nonerosive reflux disease [NERD]) receiving proton pump inhibitor (PPI) treatment has been used to select candidates for antireflux surgery. Little is known about the advantages of MII-pH monitoring compared with pH monitoring alone for evaluating GERD/NERD patients off PPI treatment considered as candidates for antireflux surgery or for assessing changes in MII-pH-detected reflux episodes after antireflux surgery. This study aimed to determine the additional value of MII over pH-metry alone for patients off PPI treatment before and after antireflux surgery. For this study 12 patients (4 women and 8 men; mean age, 45 years; range, 27-74 years) were evaluated using ambulatory MII-pH monitoring before and 3 months after mesh-augmented hiatoplasty. Reflux events were identified by MII-pH (A) and pH-metry (B) as patients recorded symptoms on a data logger. For each symptom, a symptom index was calculated for reflux events identified by MII-pH and by pH-monitoring alone. Preoperatively, MII-pH monitoring identified 71.9 +/- 8.4 reflux episodes, whereas pH monitoring identified only 51.0 +/- 7.8 (p < 0.05). Postoperatively, MII-pH monitoring identified 35.5 +/- 6.6 reflux episodes, whereas pH monitoring identified only 19.6 +/- 4.7 (p < 0.05). The pre- and postoperative symptom index for MII-pH monitoring was higher than pH monitoring (preoperative 91.7% vs 25%, p = 0.006; postoperative 50% vs 16.7%, p = 0.012). Combined MII-pH-metry improves the pre- and postoperative assessment of GERD patients off PPI and results in a higher symptom-reflux association.

Adaptation of the Visual Analog Sleep Scales to Portuguese

This article reports the adaptation of the Visual Analog Sleep (VAS) Scales developed to assess patients' perception about their sleep on the previous 24 hours. Original scales, translated to Portuguese and submitted to content validation, were tested for reliability and validity. Convenience sample was composed of 180 patients on the first postoperative day (mean age 39.3+/-12.3 years; 68.3% female). The Disturbance Scale was kept with 7 items (alpha=.80) and the Effectiveness Scale with 5 items (alpha=.78); both maintained the original structure. Item 13 (Wake after final arousal) had to be excluded from Supplementation Scale, that kept 3 out of its 4 items (alpha=.72). There was negative correlation between Disturbance and Effectiveness (r=-.68 p<.001), as it was expected. The adapted version is suitable to sleep assessment of postoperative patients. The behavior of the excluded item has to be analyzed with other samples.

Noninvasive Imaging for the Postoperative Assessment of Aortic Coarctation Patients

Noninvasive Imaging for the Postoperative Assessment of Aortic Coarctation Patients

Anatomical and clinical study of the common fibular nerve. Part 1: Anatomical study.

The aims of this research were: (1) to minimize injury to the common fibular nerve by a detailed anatomical study of the nerve and its branches and (2) clinically to establish a protocol for preoperative and postoperative assessment of patients undergoing surgery on the proximal third of the leg. Thus the incidence of fibular nerve palsy would definitely be negligible. The first part of the research consisted of an anatomical study of the common fibular nerve and its branches, paying particular attention to the motor nerve branches innervating different muscles of the leg. Dissections were done on 20 unselected lower limbs of cadavers, of unknown gender, age and dominant side, to study the anatomy of the common fibular nerve and its branches and the neighboring structures, such as the tibia, the fibula and the muscles of the leg. It was found that 76.7% of all motor nerve branches were located in the proximal third of the leg, 19.5% in the middle third and 3.8% in the distal third. The free courses of the motor nerve branches were 48.5% in the proximal third, 44.4% in the middle third and 7.1% in the distal third. Within a distance of 6 cm from the fibular head we found 51.1% of the motor nerve branches and from 6 to 11 cm there were only 25.5%. Hence there were danger zones of high and low risk for injury to the common fibular nerve and its branches. Results obtained are evaluated and discussed with regard to safer surgical approaches and insertion of Steinmann pins in the proximal third of the leg.

Late Post-reimplantation Ureteral Obstruction During Pregnancy: A Transient Phenomenon?

Patients with a history of surgical correction of vesicoureteral reflux warrant surveillance for long-term complications. However, there are little data on long-term outcome, based mainly on small series and insufficient followup. Close followup is particularly indicated during pregnancy since these patients tend to have a dilated collecting system and frequent urinary tract infections. As part of a long-term postoperative assessment of patients who underwent ureteral reimplantations in childhood, we focused on late pregnancy related obstructive dilatation associated with renal failure. Between 1970 and 1979, 322 children underwent ureteral reimplantation at our institution. A comprehensive retrospective study done to evaluate the long-term postoperative outcome, detected 2 cases of late gestational ureteral obstruction. Subsequently 2 additional cases were identified elsewhere. All 4 patients underwent successful Politano-Leadbetter ureteral reimplantation at ages 4 to 12 years. They presented during pregnancy 17 to 22 years postoperatively with progressive hydroureteronephrosis and renal failure, which required urinary drainage by percutaneous nephrostomies. Antegrade studies performed during pregnancy and in the early post-delivery period revealed severe obstruction of the distal ureters, which gradually subsided. Ureteral obstruction during pregnancy, in women who previously underwent Politano-Leadbetter ureteral reimplantation, may be attributed to high reimplantation syndrome and is likely to be a transient phenomenon. Awareness of this late and rare complication may enable us to detect this situation early, provide temporary adequate urinary drainage and prevent unnecessary surgical procedures.

REPRODUCIBILITY OF THE RADIOGRAPHIC METATARSOPHALANGEAL ANGLE IN HALLUX SURGERY

Five different methods have been described to define the longitudinal axis of the first metatarsal for radiographic measurements of the first metatarsophalangeal angle. None of these methods has been validated for both preoperative and postoperative assessment of patients undergoing hallux valgus surgery. Previous studies have demonstrated conflicting results regarding the measurement accuracy of these methods. To evaluate the measurement accuracy of these five methods, we calculated the intraobserver and interobserver coefficients of repeatability for all five methods with use of twenty preoperative and twenty postoperative standardized plain dorsoplantar weight-bearing radiographs of patients undergoing chevron distal osteotomy. The preoperative assessment of the metatarsophalangeal angle revealed small differences among the five methods. The intraobserver coefficient of repeatability ranged from 2.10 degrees to 3.34 degrees, and the interobserver coefficient ranged from 2.17 degrees to 3.44 degrees. The postoperative assessment demonstrated substantial differences between methods in which the diaphysis of the first metatarsal is used as a reference (intraobserver coefficient, 5.06 degrees to 7.23 degrees; interobserver coefficient, 5.29 degrees to 8.19 degrees) and methods in which there is one reference point in the metatarsal head and one reference point in the base of the first metatarsal (intraobserver coefficient, 1.88 degrees to 2.67 degrees; interobserver coefficient, 1.86 degrees to 2.34 degrees). For the assessment of patients undergoing a distal metatarsal osteotomy, we cannot recommend methods in which the metatarsal shaft is used as a reference for the axis of the first metatarsal. Such methods had poor measurement accuracy, especially postoperatively. Methods with reference points distal and proximal to any possible osteotomy site had much better measurement reproducibility. We recommend the method described by Miller in 1974, in which a line is drawn from the center of the first metatarsal head through the center of the base of the first metatarsal, as it was the most precise method and was least biased by postoperative effects.

Pain assessment following general anesthesia using the toddler preschooler postoperative pain scale: A comparative study

Study objectives To evaluate the reliability of the Toddler Preschooler Postoperative Pain Scale (TPPS) following general anesthesia as a guide to analgesic administration, and to compare the validity of this scale with other observational measures of pain in children. Design Prospective, consecutive, single-blinded observational study. Setting Operative and radiology suites at a community hospital. Patients 51 ASA physical status I and II patients aged 1 to 5 years requiring general anesthesia. Interventions Patients emerging from general anesthesia following elective otolaryngology, urology, and nonpainful radiology procedures were observed. Persons caring for the children were blinded as to the purpose of the observers. The observers recorded pain scores during recovery, before and after analgesic administration and at discharge. Measurements The TPPS was used in three sequential stages. The initial stage (n = 20) examined pain scores from emergence through discharge from hospital following myringotomy, adenoidectomy, or tonsillectomy. The second stage compared these pain scores to those observed on emergence from nonpainful diagnostic radiologic procedures (n = 11) and patients receiving caudal analgesia following urological procedures (n = 8). The third stage studied the clinical utility of the TPPS in comparison to the face, legs, activity, crying, consolability (FLACC) scale and a modified COMFORT scale using simultaneous measurements (n = 12). Main results TPPS scores varied in a categorical fashion with the intensity of pain and significantly decreased following opioid administration. All three scales reliably demonstrated pain reduction following opioid administration. Initial TPPS scores tended to be lower in patients who did not require treatment for pain. Conclusions Following procedures that are likely to produce pain, TPPS, FLACC, and the COMFORT scale, modified as a purely behavioral tool, can be recommended for postoperative assessment of patients aged 1 to 5 years. The TPPS may be preferred for the discrimination between painful and nonpainful states.

Obesity 01

To assess the role and workload of radiology in the postoperative assessment of patients following adjustable laparoscopic gastric band (Lap-Band) insertion. The radiological assessment of band tightness, the technique of band adjustment and the detection of complications are presented. The study population included 32 patients who had undergone Lap-Band insertion over a 4-year period. Postoperative assessment involved monitoring the patients' symptoms and weight loss by serial measurement and calculation of body mass index (BMI). All radiological interventions were documented, including contrast swallows and fluoroscopically controlled adjustments by needle access to the subcutaneous port connected to the Lap-Band device. All needle adjustments were performed using bi-plane fluoroscopy and monitored by contrast swallows. The number and nature of any radiologically detected complications were also recorded. A total of 163 radiological procedures were required in 32 patients. These included 126 needle adjustments (either tightening (injection) or loosening (aspiration) of the band) and 37 contrast swallows, where there was an apparent discrepancy between the patient's symptoms and serial weight loss assessment. Complications included gastric band leakage and erosion into the stomach lumen (three), leakage from the port and connections (two), shifting of the port (five) and rotation of the gastric band (six). Adjustable gastric band insertion is not free of complications and creates a significant and challenging postoperative workload for radiology. Particular difficulty relates to assessment of band tightness, and radiological expertise is required in needle adjustment of the band and detection of complications.

Frontal sinus surgery: Endoscopic technique

Endoscopic frontal sinus surgery, once the frontier in the evolution of endoscopic sinus surgery, is considered difficult, risky to the patient, and likely to result in a high failure rate. We clarify the surgical anatomy for frontal sinus surgery that, based on a review of our data, provides safe and predictable access to the frontal sinus. The key to safe and successful surgery of the frontal sinus is identification of the natural sinus outflow tract with preservation of at least part of the natural ostium. This is the same principle that is essential for effective surgery of the maxillary and sphenoid sinuses. We studied 200 consecutive patients with respect to indications, endoscopic and radiographic findings, results, and complications. The study will describe the technique in detail, including the following points: (1) computed tomography identification of the superior attachment of the uncinate process; (2) complete removal of the uncinate process, including its superior attachments, by using the microdebrider; (3) removal of the agger nasi and frontal cells, if present; (4) identification and preservation of the natural outflow tract; and (5) verification of an open frontal sinus by transillumination or image-guided system. Postoperative assessment of patients' symptoms and the confirmation of a patent frontal sinus by office endoscopy and transillumination indicated a 90% patency for short-term follow-up (average 12.2 months). There were no major complications. Postoperative complications included frontal recess stenosis, polypoid mucosa occluding the frontal recess, and middle turbinate lateralization. All of these situations may lead to recurrence of infection and symptoms. In-depth understanding of anatomical variations of the uncinate process and precise surgical removal of its superior attachments provide surgical access to the frontal sinus that is based on the natural ostia and is therefore more likely to remain patent.