Preoperative Respiratory Symptoms Research Articles

Association between preoperative respiratory symptoms and perioperative respiratory adverse events in pediatric patients with positive viral testing

Study objectiveTo determine the association between the presence of upper respiratory tract viral infection symptoms and occurrence of perioperative respiratory adverse events (PRAE) in children with positive viral screening, and to analyze the risk of PRAE in children with SARS-CoV-2 compared to non-SARS-CoV-2 infection. DesignA prospective cohort study. SettingA tertiary, freestanding pediatric hospital in Dallas, Texas. PatientsChildren <18 years of age with positive respiratory viral testing who underwent general anesthesia. InterventionMeasurement of incidence of PRAE and severe adverse events during the first 7 postoperative days. MeasurementsThe primary outcome was a composite of PRAE: oxygen saturation < 90% for >5 min, supplemental oxygen for >2 h after anesthesia, laryngospasm, and bronchospasm. The secondary outcome was severe adverse events: high flow nasal cannula >6 l of oxygen per minute, admission to the ICU for escalation of respiratory support post-anesthetic, acute respiratory distress syndrome, postoperative pneumonia, cardiovascular arrest, extracorporeal life support, and death. Main resultsIn this convenience sample of 196 children, 83 were symptomatic and 113 were asymptomatic. The risk of PRAE was similar in children with active viral symptoms and asymptomatic children (risk difference: −1.9%; 95% CI: −10.9, 7.9%), but higher among children with documented fever within 48 h of the anesthetic (risk difference: 20.8%; 95% CI: 5.3, 39.7%). The multivariable adjusted odds ratio of PRAE was 0.68 (95% CI: 0.25, 1.85) for symptomatic compared to asymptomatic patients, and 0.46 (95% CI: 0.14, 1.44) for patients with SARS-CoV-2 compared to non-SARS-CoV-2 infection. ConclusionsThere was no significant difference in the incidence of PRAE between symptomatic and asymptomatic children with laboratory confirmed viral respiratory infection, and between children with the Omicron variant of SARS-CoV-2 compared to non-SARS-CoV-2 respiratory viruses. However, the risk was increased in children with recent fever.

Outcomes of pulmonary artery sling repair without tracheoplasty

ObjectiveThis study aimed to investigate surgical outcomes of pulmonary artery (PA) sling without tracheoplasty. MethodsFrom 2001 through 2020, among 22 patients who underwent PA sling repair, all but 1 patient who underwent concomitant tracheal surgery were analyzed. The outcomes of interest were all-cause death, PA reintervention, tracheal intervention, and readmission for respiratory symptoms. Computed tomography was used to measure the narrowest tracheal diameter. ResultsThe median age and weight at repair were 7.6 months and 7.7 kg, respectively. Most patients (20 out of 21, 95.2%) had preoperative respiratory symptoms. Associated airway anomalies included tracheal ring in 12 (57.1%), bridging bronchus in 8 (38.1%), and tracheal bronchus in 2 patients (9.5%). There was 1 in-hospital death (4.8%). The median ventilator time and intensive care unit stay were 23 hours and 3 days, respectively. There was neither late death nor tracheal intervention during follow-up. Five patients (25.0%) underwent reintervention for left PA stenosis. Hospital readmission for respiratory symptom was required in 7 patients and was associated with the narrowest preoperative tracheal diameter (P = .025) and cardiopulmonary bypass time (P = .040) in univariable analysis. The narrowest tracheal diameter of 3.4 mm was identified as a cutoff value for readmission for respiratory symptom. Freedom from readmission for respiratory symptom was 63.3% at 10 years. ConclusionsPA sling repair without tracheal surgery might be a reasonable surgical option with rare need for tracheal intervention. Hospital readmissions for respiratory symptoms are more frequently required in patients with smaller tracheal diameter and all readmissions were limited to within 2 years after repair.

Granular cell tumor of the trachea mimicking an infiltrating thyroid cancer. A case report.

Introduction and importanceGranular cell tumor (GCT) is a rare neurogenic neoplasm originating from Schwann cells that predominantly affects women and can involve skin and mucousae. In the respiratory system it most frequently involves bronchi and larynx, while it is rare in the trachea.Case presentationA 26-year old female smoker was hospitalized for a suspected hypoechoic nodule in the right thyroid lobe closely adherent to the trachea. At preoperative computed tomography tracheal lumen was totally clear. The patient underwent a total thyroidectomy with lymph node dissection and tracheal shaving. The postoperative course was complicated by an extensive subcutaneous bilatreral emphysema associated with respiratory distress appeared on the fifth day.Bronchoscopy revealed a right anterolateral subcentimeter lesion near the second tracheal ring. Histologically, the diagnosis was consistent with a tracheal GCT developing into the thyroid parenchyma. The patient was discharged on the twentieth postoperative day. At the follow-up bronchoscopy the lesion was completely healed and at the last 12 month follow-up the patient is doing well.Clinical discussionTracheal tumors are uncommon neoplasms accounting for about 2% of the total respiratory tree tumors. In literature we found <50 papers concerning tracheal GCT and in almost all of the cases patients complained about respiratory symptoms.ConclusionWe report here a rare case of benign GCT of the trachea with extraluminal development, in a young patient who did not complain about preoperative respiratory symptoms, presented on ultrasound as a thyroid nodule with suspected cytology.

In Reply: COVID-19 Infection Affects Surgical Outcome of Chronic Subdural Hematoma.

To the Editor: We read with interest the letter “COVID-19 Infection Affects Surgical Outcome of Chronic Subdural Hematoma” by Panciani et al.1 These authors reported high mortality in 5 patients with chronic subdural hematoma (CSDH) and COVID-19. On one hand, the viral infection provoked thrombocytopenia, thus increasing the risk of postoperative hemorrhages. On the other hand, the immune system could have been impaired by surgical procedures, thus facilitating the development of interstitial pneumonia (IP). Indeed, as the authors correctly stated, presently, there are no reliable data regarding the neurosurgical outcome of COVID-19 patients. After the outbreak of the COVID-19 contagion in Lombardy, our department suspended elective surgery and became one of 3 regional hubs for neurosurgical emergencies. During the last month, we surgically managed 4 symptomatic patients with CSDH and COVID-19: 2 males and 2 females. Mean age was 75.5 yr. None presented preoperative respiratory symptoms. Of these patients, 2 were taking chronic antiplatelet drugs and 1 had a history of chronic liver failure. In all cases, the CSDH was monolateral. All patients were operated under local anesthesia and received postoperative prophylaxis by low-molecular-weight heparin before mobilization. There was 1 case of severe postoperative IP: an 85-yr-old woman died 3 wk after surgery. Mild thrombocytopenia was found in 2 patients and was promptly corrected without any significant problem or postoperative rebleeding. Three patients fared well for what concerns both the CSDH and the evolution of COVID-19. Of course, this series is too small to draw any conclusion. Undoubtedly, neurosurgical procedures may have the potential to worsen the course of COVID-19. However, IP occurred only in our oldest patient, and age is a well-known risk factor regardless of the surgical treatment. Except for this case, neurosurgical treatment and COVID-19 did not seem to influence each other significantly. We suppose that a role could have been played by anesthesia: All our patients were managed under local anesthesia, whereas Panciani and colleagues1 operated their patients under general anesthesia. In our experience, general anesthesia did not represent a problem in younger COVID-19 patients. Accordingly, the combined effect of age and anesthesia might be crucial. A final brief comment is deserved by the reliability of nasopharyngeal swab in these patients. Two individuals underwent surgery with an already ascertained diagnosis of COVID-19 and early started antiretroviral therapy with lopinavir/ritonavir and hydroxychloroquine. Conversely, both the remaining 2 patients were studied by 2 repeated preoperative swabs, which always resulted negative. The diagnosis was ascertained postsurgery. Since one of these 2 patients was the elderly woman who developed lethal IP, perhaps this diagnostic delay could have been important. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

Evaluation of Spirometric Testing as a Routine Preoperative Assessment in Patients Undergoing Bariatric Surgery

The value of spirometry as a routine preoperative test for bariatric surgery is debatable. The aim of this study was to assess the relationship between spirometry results and the frequency of postoperative pulmonary complications in 602 obese patients. Clinical files of patients undergoing bariatric surgery between 2004 and 2013 were reviewed. Demography, risk factors, respiratory symptoms, and spirometry results (forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), FEV1/FVC) were recorded, and their relationship with postoperative pulmonary complications was evaluated. There were 256 males and 346 females with a mean age of 40.2 ± 11.6 years and a mean BMI of 42.1 ± 6.4 kg/m2. History of smoking was found in 408 patients (68 %). Preoperative respiratory symptoms were present in 328 (54.5 %). Most frequent symptoms were snoring (288), dyspnea (119), bronchospasm [6], and chronic productive cough [6]. In 153 patients, history of respiratory disease was documented. The obstructive sleep apnea syndrome (OSAS) was present in 124, 20 requiring continuous positive airway pressure (CPAP). Asthma was present in 27 and chronic obstructive pulmonary disease (COPD) in 2. Variables associated to a higher risk of pulmonary complications were OSAS (OR 2.3), an abnormal spirometry (OR 2.6), male gender (OR 1.9), and preoperative respiratory symptoms (OR 1.9). Using multivariate logistic regression, an abnormal spirometry was a significant predictor of postoperative pulmonary complications in patients with respiratory symptoms and/or OSAS. However, it lost prognostic significance when both conditions were subtracted. In obese patients undergoing bariatric surgery, abnormal preoperative spirometry predicts postoperative respiratory complications only in patients with OSAS.

Predictive Factors Involved in Development of Postoperative Pulmonary Complications.

In the present study, we applied the method of the multi-center Prospective Evaluation of a Risk Score for postoperative pulmonary Complications in Europe (PERISCOPE) study, which was designed to predict postoperative complications and funded by the European Society of Anaesthesiology, to patients in our institution with the aim of prospectively analyzing the postoperative risk factors of pulmonary complications. One hundred patients over 18 years of age who had emergency or elective non-thoracic or non-obstetric surgery under general anaesthesia or neuraxial blocks were included in the study. Collected data regarding the preoperative and postoperative period were filled in separate forms for all patients. A total of 11 patients developed pulmonary complications. We observed respiratory failure in 8 patients, pleural effusion in 3 patients, atelectasis in 5 patients, bronchospasm in 3 patients, and pneumothorax in 1 patient. In the univariate logistic regression model, patient age, gender, weight, rate of preoperative respiratory symptoms, cough test results, American Society of Anesthesiology (ASA) score, and the duration of surgery did not significantly increase the complication risk (p>0.05). However, in the univariate logistic regression model, the presence of respiratory symptoms increased the risk for complications approximately 5.34-fold (p=0.014). There was an increase in the possibility of complications in parallel with the increase in the duration of postoperative hospital stay (p=0.012). More respiratory symptoms (p=0.019) and longer hospital stay (6.5 vs. 3.5 days respectively, p=0.029) were recorded in patients with postoperative pulmonary complications. Considering patients undergoing non-thoracic or non-obstetric surgery, the prevalence of postoperative pulmonary complications is higher in patients diagnosed with respiratory symptoms in the preoperative period. These complications significantly extend the length of hospital stay.

Is Tracheoplasty Necessary for All Patients With Pulmonary Artery Sling and Tracheal Stenosis?

Pulmonary artery sling frequently accompanies various degrees of tracheal stenosis. The authors reviewed their surgical outcomes for pulmonary artery sling from two institutions. From 1997 to September 2011, 16 patients with pulmonary artery sling underwent surgical treatment. Their median age was 4.6months and their body weight 6.2kg at the time of the operation. Of the 16 patients, 12 showed preoperative respiratory symptoms such as recurrent airway infection or dyspnea, with three of these patients receiving ventilator therapy preoperatively. Most of the patients showed various degrees of tracheal luminal stenosis and stenotic length, except for three patients who did not show significant airway stenosis. Left pulmonary artery reimplantation was performed for all the patients, but an accompanying tracheoplasty was performed for only two patients (one patch augmentation and one sliding tracheoplasty). After surgery, early extubation and intensive lung care were performed. Two operative mortalities occurred: one due to cardiac tamponade associated with postoperative bleeding and one due to aggravation of preexisting multiorgan failure. Two late mortalities occurred: one due to airway obstruction by repetitive granulation tissue growing at the tracheoplasty site and one due to pneumonia. The 12 living patients, including 11 patients who did not undergo tracheal surgery, showed no clinically significant airway problems at their last follow-up visit. The surgical outcomes for pulmonary artery sling without tracheoplasty were acceptable. The authors think tracheoplasty may be avoided by intensive postoperative airway management for a significant portion of the patients with pulmonary artery sling and tracheal stenosis.

Eisenmenger Ventricular Septal Defect: Classification, Morphology, and Indications for Surgery

This study aimed to examine the definition and indications for surgery, to elucidate the morphologic substrate of aortic regurgitation, and to extrapolate the pathologic mechanisms of subpulmonary stenosis in Eisenmenger ventricular septal defect (EVSD). The study enrolled 160 patients. Preoperative respiratory symptoms and poor growth were present in 41 patients (26%), and 21 patients (13%) required mechanical ventilation. Perimembranous ventricular septal defect (pVSD) had been diagnosed previously for 136 of the patients (85%) at other institutions. Of the 160 patients, 51 (32%) had muscular posteroinferior rims. Aortic regurgitation was experienced by 36 patients (23%), found to be mild in 31 cases (19%) and moderate in 5 cases (3%). None of the patients had severe regurgitation. No aortic valvuloplasty was performed. The significant risk factors for aortic regurgitation were subpulmonary stenosis (p=0.001) and a muscular posteroinferior rim (p=0.000). Subpulmonary stenosis was seen in 57 patients (35%), found to be mild to moderate in 42 cases (26%) and severe in 15 cases (9%). Adequacy of the stenosis band was repaired through the tricuspid valve for 57 of these patients. The definition of EVSD should identify it as a subgroup different from pVSD, and it should be closed as soon as it is identified in developing countries. Aortic regurgitation occurs rarely, and aortic valvoplasty should be performed if it exceeds a moderate level. The subpulmonary stenosis can be repaired through the tricuspid valve.

Validity of the Spanish 8-item Short-form Generic Health-related Quality-of-Life Questionnaire in Surgical Patients

Health-related quality of life is usually reported for specific rather than heterogeneous populations such as those treated in routine anesthesia practice. The 8-item short-form generic health-related quality-of-life questionnaire (SF-8) is a candidate instrument for this setting. The authors evaluated the feasibility, reliability, validity, and responsiveness to change of the Spanish version of SF-8 in a population-based surgical cohort. Recruiting patients from a large population-based study of risk factors for pulmonary complications, before surgery, the authors administered the 1-week recall SF-8 to 2,991 patients undergoing nonobstetric elective or emergency surgery in 59 hospitals, each of which collected data on seven randomly assigned days in 2006. The SF-8 was administered again 3 months later. Reliability was evaluated using the Cronbach alpha coefficient and validity by comparing physical and mental component summary SF-8 scores with clinical variables. Responsiveness after surgery was evaluated using the standardized response mean. Cronbach alpha for the overall test was 0.92. Physical and mental component summary scores and all individual scores were lower (worse quality of life) in women (P < 0. 01) and decreased with age (P < 0.01). Preoperative scores were lower for those in worse clinical condition (higher body mass index, American Society of Anesthesiologists physical status class, or surgical risk scores), with preoperative respiratory symptoms, and in emergency situations (P < 0.01). The standardized response mean ranged from 0.1 to 0.5. The SF-8 is a feasible, reliable, valid, and responsive instrument for assessing health-related quality of life in a broad-spectrum surgical population.

Thoracoscopic versus open resection for congenital cystic adenomatoid malformations of the lung

This study evaluated the potential advantages of thoracoscopy compared to thoracotomy for resection of congenital cystic adenomatoid malformations (CCAM). We conducted a retrospective chart review of consecutive cases of CCAM resection at University of California San Francisco Children's Hospital from January 1996 to December 2006. Thirty-six cases of postnatal CCAM resections were done over the past 10 years; 12 patients had thoracoscopic resections, whereas 24 patients had open resections. Patients in the thoracoscopic group had significantly longer operative time (mean difference of 61.3 minutes; 95% confidence interval [CI], 30.5-92.1) but shorter postoperative hospital stay (mean difference of 5.7 days; 95% CI, 0.9-10.4) and duration of tube thoracostomy (mean difference of 2.6 days; 95% CI, 0.7-4.5) and lower odds of postoperative complications (odds ratio of 9.0 x 10(-4); 95% CI, 8.0 x 10(-6)-0.1). In the subgroup analysis of only asymptomatic patients, the thoracoscopy group still had a significantly shorter hospital stay (mean difference of 2.8 days; 95% CI, 0.7-4.8). There was also a pattern for reduced complications in the thoracoscopy group (OR, 0.13; 95% CI, 0.02-1.0; P = .05). The average hospital costs were similar in both groups. With a conversion rate of 33% (6/18), patients with a history of preoperative respiratory symptoms had a higher incidence of conversion than those who were asymptomatic (66.7% vs 0%, P = .005). These four patients had a history of pneumonia. Minimally invasive resection of CCAM results in longer operative time but shorter hospital stay, potentially reduced complications, and no additional hospital costs. Thoracoscopic lobectomy in patients with a history of pneumonia is challenging and a risk factor for conversion to thoracotomy.

RISK FACTORS FOR POSTOPERATIVE PULMONARY COMPLICATIONS IN UPPER ABDOMINAL SURGERY

Pulmonary complications are the most frequent cause of postoperative morbidity and mortality in upper abdominal surgery (UAS). We aimed to examine the influence of possible preoperative, operative and postoperative risk factors on the development of early postoperative pulmonary complications (POPC) after UAS. A prospective study of 60 consecutive patients was conducted who underwent elective UAS in general surgical unit. Each patient's preoperative respiratory status was assessed by an experienced chest physician using clinical examination, chest radiographs, spirometry and blood gas analysis . Anaesthetical risks, surgical indications, operation time, incision type, duration of nasogastric catheter and mobilization time were noted. Forty-eight hours after the operation, pulmonary examinations of the patients were repeated. Postoperative pulmonary complications were observed in 35 patients (58.3%). The most common complication was pneumonia, followed by pneumonitis, atelectasis, bronchitis, pulmonary emboli and acute respiratory failure. The presence of preoperative respiratory symptoms and the spirometric parameter of forced expiratory volume in 1 s/forced vital capacity were the most valuable risk factors for early prediction of POPC. The sensitivity, specificity and diagnostic efficiency of the presence of preoperative respiratory symptoms in the POPC prediction were 70, 61 and 66%, respectively. We recommend a detailed pulmonary examination and spirometry in patients who will undergo UAS by chest physicians to identify the patients at high risk for POPC, to manage respiratory problems of the patients before surgery and also to help surgeons to take early measures in such patients before a most likely POPC occurrence. Improvement of lung function in those patients at risk for POPC before operation may decrease morbidity in surgical patients.

The correlation between preoperative pulmonary function and postoperative pulmonary complications in the surgical treatment of scoliosis

To evaluate the incidence of immediate postoperative pulmonary complications and their correlation to preoperative pulmonary function tests (PFTs), preoperative pulmonary symptoms and surgical approaches. The case records of 298 patients, who underwent anterior or posterior fusion, were reviewed. Preoperative PFTs were recorded and abnormal PFTs were defined as forced vital capacity (FVC) is less than 80% of FVC predicted. Preoperative pulmonary symptoms (breathless on exertion) were noted, and postoperative pulmonary complications were defined when the presence of atelectasis, infiltrates, pneumothorax, hemothorax, pneumonia or requirement of postoperative ventilatory support was noted. The mean age of this group was 16.4 years (range from 6-62 years). The average coronal Cobb angle was 73.26 degrees (range from 45 degrees-141 degrees ). Of all the patients, 115 patients had normal preoperative PFTs, the other 183 cases had abnormal PFTs. Nineteen cases of all the patients were found with postoperative pulmonary complications including postoperative ventilatory support in 6 cases, atelectasis in 4 cases, infiltration in 2 cases, pneumothorax in 3 cases, pneumonia in 3 cases and hypoxemia in 1 case. The incidence of postoperative pulmonary complication was 6.4% in all the patients, while 18.99% in the 79 patients with thoracotomy and 1.85% in the 216 patients without. The correlation between postoperative pulmonary complications and the surgical approach was statistically significant (P=0.0000). When the patients were classified into 3 groups: 60%< FVCR <80%, 40%< FVCR <60%, FVCR <40%, the incidence of postoperative pulmonary complications were 2.72% (3/110), 7.40% (4/54) and 31.6% (6/19) respectively, which showed an increasing complication incidence. In the 115 patients with normal PFTs, 3 patients had preoperative pulmonary symptoms (2.68%), while 14 of the 183 patients with abnormal PFTs had preoperative pulmonary symptoms (7.65%). The correlation between presence of preoperative respiratory symptoms and abnormal results on PFTs was statistically significant (P=0.01). No significant correlation was found between preoperative respiratory symptoms and postoperative pulmonary complications (P=0.52). The incidence of postoperative pulmonary complications increases with the deterioration of PFTs. The posterior procedure has a very low incidence of postoperative pulmonary possibility of complications, but a transthoracic procedure increases the complications significantly. Preoperative respiratory symptoms usually predict abnormal results of PFTs but have no correlation with postoperative pulmonary complication.

Clinical and functional results after Laparoscopic fundoplication. Prospective evaluation

To prospectively assess the medium- and long-term clinical and functional results in consecutive patients undergoing laparoscopic procedures for gastroesophageal reflux. The series included the interventions performed or assisted by the first author in 325 patients referred for surgical evaluation between December 1992 and June 2000. Forty patients were excluded from the study because they did not fulfil the inclusion criteria for laparoscopic surgery. A further 20 patients who underwent laparoscopic surgery were excluded because they required conversion to open surgery. Thus, 265 patients were included in the study. One hundred ninety-six total fundoplications (Nissen-Rossetti) and 69 partial fundoplications(42 posterior-Toupet and 27 anterior-Dor) were performed. The surgical technique employed was a slight modification of that described by Dallemagne et al with five-trocars. Preoperative evaluation was established by clinical features, endoscopy with biopsy, barium contrast radiography, esophageal manometry and esophageal pH monitoring. The mean follow-up was 47.1 3.3 months (range: 4-92 months). Heartburn, regurgitation, and dysphagia were relieved in 92.5%, 97.7%, and 88.1% of patients respectively. Complete relief of symptoms was achieved in all patients who presented preoperative respiratory symptoms as a complication of gastroesophageal reflux. Esophagitis healed in 98.2% of patients with preoperative esophagitis. Correction of lower esophageal sphincter pressure and lower esophageal sphincter length were statistically significant compared with preoperative status (p = 0.006 and p = 0.003, respectively). Pre- and postoperative differences in the percentage of patients with a pH < 4 in 24-hour ambulatory esophageal pH monitoring were also significant (p = 0.005), confirming correction of acid reflux. Morbidity appeared in 6.7% of patients and there was no mortality. Conversion to open procedures was required in 7.5%. The mean operative time was 115 6.3 minutes. These preliminary results suggest that when performed by experienced surgeons laparoscopic fundoplication provides an excellent alternative in selected patients with gastroesophageal reflux. Both medium- and long-term clinical and functional results, as well as morbidity, were satisfactory and were similar to those of open fundoplication.

Repair of Pectus Excavatum Deformities: 30 Years of Experience With 375 Patients

To review the surgical experience with pectus excavatum chest deformities at UCLA Medical Center during a 30-year period. Pectus excavatum is a relatively common malformation that is often symptomatic; however, children's physicians often do not refer patients for surgical correction. Hospital records from 375 patients who underwent repair of pectus excavatum deformities between 1969 and 1999 were reviewed. Decrease in stamina and endurance during exercise was reported by 67%; 32% had frequent respiratory infections, 8% had chest pain, and 7% had asthma. The mean pectus severity score (width of chest divided by distance between posterior surface of sternum and anterior surface of spine) was 4.65 (normal chest = 2.56). All patients had marked cardiac deviation into the left chest. Repair was performed with subperiosteal resection of the abnormal cartilages, transverse wedge osteotomy of the anterior sternum, and internal support with a steel strut for 6 months. Repair was performed on 177 children before age 11 years; 38 adults with severe symptoms underwent repair. The mean hospital stay was 3.1 days. With a mean follow-up of 12.6 years, all patients with preoperative respiratory symptoms, exercise limitation, and chest pain experienced improvement. Vital capacity increased 11% (mean) within 9 months in 35 patients evaluated. There were no deaths. Complications included hypertrophic scar formation (35), atelectasis (12), pleural effusion (13), recurrent sternal depression (5), and pericarditis (3). More than 97% had a very good or excellent result. Pectus excavatum deformities can be repaired with a low rate of complications, a short hospital stay, and excellent long-term physiologic and cosmetic results.