Prevention Of Intraoperative Complications Research Articles

Innovative Technologies in the Monitoring of the Age-Related Cataract

Literature review is devoted to modern high-technology instrumental methods of the lens evaluation, which have been developed to improve efficiency of the diagnostics and management of cataract in ophthalmological clinical practice. The slit-lamp examination of lens and retroillumination images are used for subjective assessment of cataract according to LOCS III grading system. Currently objective methods of lens evaluation have practical value and provide information about early age-related changes of crystalline lens with the quantitative assessment of the severity of opacities including the optical and ultrasound examinations. Optical methods include densitometry using Scheimpflug images obtained from applications to quantify the localization of lens opacities and their progression rate. Another method is the intensity distribution analysis of the wave front of the optical aberrations according to grading cataract severity with the objective scatter index (OSI) obtained by double-pass technology. Moreover the optical quantitative assessment of lens opacities is carried out by the Shack—Hartmann wave front sensor to identify the grade of nuclear opalescence (N-type) with the Lens Opacities Classification System III. This method is very helpful in nuclear cataract. Swept source optical coherent tomography (SS-OCT) with variable length of wave and high frequency detector is used for the density measurements of nuclear and cortical opacities of lens imaging in micro- and macro dimensional scale. Ultrasound biomicroscopy is the most informative ultrasonic diagnostic method for the evaluation of acoustic density and early age-related changes of lens. Current high-informative methods of quantitative assessment of the optical density of lens are helpful in determination of indications for surgery, the optimization of phacoemulsification settings and prevention of intraoperative complications. The use of high-technologic methods demonstrated the effectiveness of eye drops 0,005 % pirenoxine in early lens opacities management.

Short-term results of two strategies in thoracoscopic ablation for lone atrial fibrillation

Background: Thoracoscopic ablation is an effective treatment of patients with atrial fibrillation. Nowadays, 2 types of ablative devices are available in clinical practice allowing one to perform the thoracoscopic procedure Medtronic and AtriCure. However, the contemporary clinical literature does not have enough data that would compare these two approaches. Aims: to perform a comparative analysis of the short-term results of two minimally invasive strategies in thoracoscopic ablation for atrial fibrillation. Methods: 232 patients underwent thoracoscopic ablation for atrial fibrillation in two clinical centers for the period from 2016 to August 2021. The patients were divided into 2 groups. The first group was represented by those patients to whom a Medtronic device was applied (n=140), the second group was treated with an AtriCure device (n=92). The patients were comparable in their age, gender, initial severity of the condition. The follow-up consisted of laboratory tests, chest Х-ray, electrocardiography, 24-hour Holter monitor, echocardiography. The structure and prevalence of postoperative and intraoperative complications, specifics of the postoperative period were compared between the two groups. Results: According to the structure and prevalence of intraoperative complications the 2 groups are comparable to each other: 4.3% and 1.1% for the 1st group and 2nd group, respectively (p 0.05). The postoperative complications had developed in 6 (4.3%) and 5 (5.4%) patients in groups 1 and 2, respectively (p 0.05). At the time of discharge from hospital, a sinus rhythm was registered in 93.6% of patients (1st group), and 85.9% (2nd group) (p 0.05). Conclusions: Both strategies have demonstrated comparable short-term results in patients with lone atrial fibrillation. A further research is needed to evaluate the effectiveness of this strategy in a long-term period.

Indocyanine Green Endoscopy for Pituitary Adenomas with Parasellar Extension: Results from a Preliminary Case Series

Advances in visualization tools have brought new confidence, including endoscope-integrated indocyanine (E-ICG), which makes pituitary and skull-base surgery safer and more effective. We report here our preliminary experience with the use of E-ICG to 1) visualize the cavernous segment of the internal carotid artery (ICA); and 2) functionally and anatomically preserve the pituitary gland. A dedicated ICG-integrated endoscope was used in 15 patients with parasellar pituitary adenomas. Indocyanine was administered at 2 different time points during surgery: an early bolus of 12.5 mg at the sphenoid sinus opening to expose the position of the parasellar segment of the ICAs and to identify the position of the normal pituitary gland so that it could be preserved during tumor removal. Subsequently, a second late bolus of 12 mg of ICG was injected to obtain a real-time "wire angiographic" visualization of the flow of the ICAs. Gross total resection was achieved in 12 cases (80%), whereas subtotal resection was performed in the other 3 cases (20%). The pituitary gland was clearly discernable in 11 cases (91.6%). None of the patients manifested new endocrinologic deficits or major vascular complications. E-ICG is a safe and essential aid for pituitary adenomas invading the cavernous sinus. Its performance as a pituitary marker and real-time video angiography showed promising results in terms of extent of resection, endocrinologic outcomes, and prevention of intraoperative complications.

THE EFFECT OF INHALED MILRINONE ON PULMONARY ARTERIAL PRESSURE IN PATIENTS UNDERGOING CARDIAC SURGERY

ABSTRACT
 Objective: To find out the effect of inhaled Milrinone on pulmonary arterial pressure in patients undergoing cardiac surgery.
 Methods: A randomized controlled trial was done at Peshawar Institute of Cardiology in 78 patients who had preoperative pulmonary hypertension and had undergone cardiac surgery between the ages of 3 months and 60 years. Divided into 2, group 1 received Intravenous (IV) Milrinone and group 2 received Inhalational (IN) Milrinone. MANOVA was used to compare the difference between two groups across six dependent variables i.e., Heart rate (HR), systolic arterial pressure (SAP), Central venous pressure (CVP), Systolic pulmonary arterial pressure (SPAP), Diastolic pulmonary arterial pressure (DPAP) and Diastolic pulmonary arterial pressure (MPAP) at three stages; baseline, end of nebulization, and after cardiopulmonary bypass (labeled as stages 1,2 and3).
 Intraoperative complications like weaning from cardiac bypass (CBP) machine, use of vasopressor, insertion of intra-aortic balloon pump (IABP), and cardiopulmonary re-initiation were also observed in both the groups. Analysis of the data was done through SPSS-23.
 Results: In a total of 78 patients (39 in each group), an insignificant change was observed regarding the effects of IN Milrinone on HR, SAP, and CVP whereas significant effects of Inhaled Milrinone on SPAP, DPAP, and MPAP were observed (P-values <0.05).
 Conclusion: The use of inhaled Milrinone was beneficial in patients with pulmonary hypertension in the prevention of Intraoperative complications like difficulty in weaning from CPB, insertion of IABP, and use of vasopressors, while CPB re-initiation was observed less in patients with inhalational milrinone as compared with intravenous administration while reducing their length of stay in ICU.
 Key Words: inhaled Milrinone, pulmonary artery pressure, cardiac surgery.
 
 

Revisiting Fulkerson's Original Technique for Tibial Tubercle Transfer: Easing Technical Demand and Improving Versatility

Tibial tubercle osteotomy is a well-described treatment option for a variety of patellofemoral disorders. Many techniques have evolved since its inception, including combinations of anteriorization, medialization, and distalization of the tibial tubercle. Although differing in their indications and end goal destination of the tubercle, these techniques share the challenging technical demands of achieving successful correction based off preoperative planning and prevention of intraoperative complications. We present our technique using osteotomy guide pins in a medial to lateral direction, originally described by Fulkerson in 1982. The advantages of our technique include better visualization for angle of osteotomy confirmation; versatility that provides options for any combination of anteriorization, medialization, or distalization; and the opportunity to maintain a distal cortical hinge if so desired.

Rate of intraoperative complications during cataract surgery following intravitreal injections.

PurposeTo investigate the effect of prior intravitreal injections on intraoperative and postoperative complication rates associated with cataract surgery.MethodsA retrospective cohort analysis reviewed 10 105 cataract surgery procedures performed by experienced surgeons at the Duke Eye Center from 1 January 2005 to 10 December 2012. A group of 197 eyes with prior intravitreal injections was compared with an equal number of matched control eyes without prior injection using the Fisher's exact test of difference in proportions and the Wilcoxon rank-sum test of difference in means. Outcomes analyzed included baseline demographic information, preoperative clinical characteristics, prevalence of intraoperative complications, and postoperative intraocular pressure, glaucoma surgery, and glaucoma medication requirement through 1 year following cataract surgery.ResultsAn increased rate of intraoperative complications was identified during cataract surgery in eyes with prior intravitreal injections compared with control eyes (3 vs 0%, P=0.030). Injection eyes required more glaucoma medications at 1 year, but no difference was identified if steroid injections were excluded. No difference in postoperative IOP or glaucoma surgery was identified. No cases of endophthalmitis were reported.ConclusionsA history of intravitreal injections may be a risk factor for cataract surgery-related intraoperative complications. We hypothesize this may be due to unidentified iatrogenic lens trauma during intravitreal injections. Particular attention to the posterior capsule during preoperative assessment and intraoperatively is recommended in eyes undergoing cataract surgery with a prior history of intravitreal injections.

Maternal complications in repeated Caesarean section

Maternal complications in repeat cesarean section are increasing with the rising rate of cesarean section in the world. The aim of this study to evaluate intra-operative maternal complications of previous one and two cesarean section. It needs to the highlight for proper antenatal care and complication can be anticipated during surgery.Objective:To determine the frequency of intra-operative maternal complications among women undergoing repeated Caesarean section at Isra University hospital, Hyderabad.Material and methods:STUDY DESIGN: Cross-sectionalSETTING: The study was conducted obstetric and gynecology department of Isra University Hospital Hyderabad.DURATION OF STUDY: The study was of six months and the study process was carried out from 15th Agust 2011 to 15th February 2012.SAMPLE SIZE: 280 casesSAMPLE TECHNIQUE: Non probability, purposive samplingSAMPLE SELECTION:Inclusion criteria: All the pregnant women with history of previous one and previous to caesarean section availing obstetric and gynecology facilities at Isra University Hospital, Hyderabad Women regardless of any age group.  Exclusion criteria:•         Pregnant women with no history of caesarean section•         Pregnant women who refused to participate in the studyRESULTS:     The mean + SD age was found to be 29.94 + 5.03 years; The maximum age of participants in this study was 45 years while the minimum age was 17 years. The age distribution of study participants was normally distributed. Regarding intra-operative complications, the prevalence of Adhesion is very high and alarming i.e. 97.5% among pregnant women undergoing repeated Caesarean section delivery. The prevalence of uterine scar dehiscence was not very high and it was confined to 17.9% in our study. The prevalence of difficult delivery of fetus a maternal complication was around 12% in our sample. The prevalence of excessive blood loss as an Intra-operative maternal complication was found to be 19% in our study. The prevalence of Caesarean Hysterectomy as an Intra-operative maternal complication was very minimum i.e. <2% in our sample. With regard to the association of age with intra-operative complication Adhesion among study participants, there was no difference in the mean age of two groups as evidenced by p-value of 0.103. Moreover, there was no association between age with intra-operative complication uterine scar dehiscence as evidenced by p-value of 0.837. Interestingly no association was observed between previous history of Caesarean section with intra-operative complication Adhesion among study participants. There was a significant association between previous history of Caesarean section and uterine scar dehiscence in our study.Conclusion: The present research makes a strong case that the prevalence of intra-operative complications among pregnant women undergoing repeated Caesarean section is not uncommon at Isra University hospital Hyderabad, Pakistan. This issue can have serious implications for maternal mortality and morbidity. Multiple cesarean deliveries are associated with one of the intra-operative complications “Uterine scar dehiscence”. The risk of major complications increases with cesarean delivery number.

Maternal complications in repeated Caesarean section

Maternal complications in repeat cesarean section are increasing with the rising rate of cesarean section in the world. The aim of this study to evaluate intra-operative maternal complications of previous one and two cesarean section. It needs to the highlight for proper antenatal care and complication can be anticipated during surgery.Objective:To determine the frequency of intra-operative maternal complications among women undergoing repeated Caesarean section at Isra University hospital, Hyderabad.Material and methods:STUDY DESIGN: Cross-sectionalSETTING: The study was conducted obstetric and gynecology department of Isra University Hospital Hyderabad.DURATION OF STUDY: The study was of six months and the study process was carried out from 15th Agust 2011 to 15th February 2012.SAMPLE SIZE: 280 casesSAMPLE TECHNIQUE: Non probability, purposive samplingSAMPLE SELECTION:Inclusion criteria: All the pregnant women with history of previous one and previous to caesarean section availing obstetric and gynecology facilities at Isra University Hospital, Hyderabad Women regardless of any age group.  Exclusion criteria:•         Pregnant women with no history of caesarean section•         Pregnant women who refused to participate in the studyRESULTS:     The mean + SD age was found to be 29.94 + 5.03 years; The maximum age of participants in this study was 45 years while the minimum age was 17 years. The age distribution of study participants was normally distributed. Regarding intra-operative complications, the prevalence of Adhesion is very high and alarming i.e. 97.5% among pregnant women undergoing repeated Caesarean section delivery. The prevalence of uterine scar dehiscence was not very high and it was confined to 17.9% in our study. The prevalence of difficult delivery of fetus a maternal complication was around 12% in our sample. The prevalence of excessive blood loss as an Intra-operative maternal complication was found to be 19% in our study. The prevalence of Caesarean Hysterectomy as an Intra-operative maternal complication was very minimum i.e. <2% in our sample. With regard to the association of age with intra-operative complication Adhesion among study participants, there was no difference in the mean age of two groups as evidenced by p-value of 0.103. Moreover, there was no association between age with intra-operative complication uterine scar dehiscence as evidenced by p-value of 0.837. Interestingly no association was observed between previous history of Caesarean section with intra-operative complication Adhesion among study participants. There was a significant association between previous history of Caesarean section and uterine scar dehiscence in our study.Conclusion: The present research makes a strong case that the prevalence of intra-operative complications among pregnant women undergoing repeated Caesarean section is not uncommon at Isra University hospital Hyderabad, Pakistan. This issue can have serious implications for maternal mortality and morbidity. Multiple cesarean deliveries are associated with one of the intra-operative complications “Uterine scar dehiscence”. The risk of major complications increases with cesarean delivery number.

Complications of Cataract Surgery in Iran: Trend from 2006 to 2010

ABSTRACTPurpose: To determine intraoperative complications of cataract surgery over the period 2006 to 2010.Methods: In this cross-sectional study, 106 of 272 cataract surgical centers in Iran were selected through multistage random cluster sampling from all provinces. In each province, the selected number of centers was proportionate to the number of cataract surgeries, and in each center, the selected number of charts was proportionate to the center’s number of cataract surgeries, from which we retrieved intraoperative complications.Results: The prevalence of intraoperative complications of cataract surgery was 5.04% (95% confidence interval, CI, 3.53–6.54%) in 2006, which decreased significantly to 3.44% (95% CI 1.84–5.04%) in 2010. The most common complication was posterior capsular rupture/vitreous loss which decreased from 4.29% (95% CI 2.93–5.66%) in 2006 to 2.81% (95% CI 1.3–4.31%) in 2010. The next most common complication was suprachoroidal hemorrhage at 0.56% (95% CI 0.25–0.87%) in 2006 and 0.46% (95% CI 0.3–0.62%) in 2010. The least common complication concerned intraocular lens (IOL)-drop. Complications were seen most with lensectomy, while phacoemulsification caused the least complications. Mean hospitalization time in uncomplicated cases was 0.59 days (95% CI 0.58–0.61 days) and in complicated cases 1.14 days (95% CI 1.07–1.20 days; p < 0.001).Conclusion: Complications of cataract surgery in Iran had a decreasing trend during 2006–2010. However, results from 2010 indicate that cataract surgical complications still need to be focused on. Hospitalization was longer for cases with complications, and further reducing this could help decrease costs of cataract surgery.

Efficacy and safety of the pterional keyhole approach for the treatment of anterior circulation aneurysms.

Keyhole surgery is partly replacing the standard pterional approach in patients undergoing surgery to treat aneurysms of the anterior circulation. We describe the pterional keyhole approach for the clipping of anterior circulation aneurysms and discuss the efficacy and safety of our keyhole craniotomy procedure. We treated 103 patients with 111 intracranial aneurysms by surgical clipping via the pterional keyhole approach and retrospectively compared the characteristics and clinical outcomes of the keyhole procedure and the standard pterional approach. We also compared the surgical results of the keyhole approach when the operator was an experienced neurosurgeon or a less experienced neurosurgeon guided by an experienced colleague. All keyhole operations were carried out successfully without enlargement of the craniotomy or a change to a different approach. The outcomes of the keyhole and the standard pterional approach in patients with subarachnoid hemorrhage were not significantly different. Favorable outcomes were obtained in patients with unruptured aneurysms treated by either experienced or less experienced surgeons. The pterional keyhole approach offers the same surgical possibilities as conventional pterional approaches for the treatment of anterior circulation aneurysms. It is safe and simple and yields favorable outcomes even if the operators are less experienced neurosurgeons. Careful patient selection and sufficient opening of the sylvian fissure are the key points for good outcomes and the prevention of intraoperative complications.

Intraoperative Floppy Iris and Prevalence of Intraoperative Complications: Results From Ophthalmic Surgery Outcomes Database

To estimate the prevalence of untoward events during cataract surgery with the use of pupillary expansion devices and intraoperative floppy iris (IFIS). Retrospective analysis of 4923 cataract surgery cases from the Veterans Affairs Ophthalmic Surgical Outcomes Data Project. Outcomes from 5 Veterans Affairs medical centers were analyzed, including use of alpha-blockers (both selective and nonselective), IFIS, intraoperative iris trauma, intraoperative iris prolapse, posterior capsular tear, anterior capsule tear, intraoperative vitreous prolapse, and use of pupillary expansion devices. P values were calculated using the χ(2) test. A total of 1254 patients (25.5%) took alpha-blockers preoperatively (selective, 587; nonselective, 627; both, 40). Of these 1254 patients, 428 patients (34.1%) had documented IFIS. However, 75.2% of patients with IFIS (428/569) had taken alpha-blockers preoperatively (P < .00001). A total of 430 patients (8.7%) had a pupillary expansion device used during their cataract surgery, of which 186 patients (43.4%) had IFIS (P < .0001). Eighty-six patients with IFIS had at least 1 intraoperative complication and 39 patients with IFIS had more than 1 intraoperative complication (P < .001). The use of either selective or nonselective alpha-antagonists preoperatively demonstrated a significant risk of IFIS. Nonselective alpha-antagonists caused IFIS at a higher prevalence than previously reported. This study did demonstrate statistically significant increased odds of surgical complications in patients with IFIS vs those without IFIS in all groups (those taking selective and nonselective alpha-antagonists and also those not taking medications).

Intraoperative floppy iris syndrome (IFIS): what complication rates can we expect?

Dear Editor, In a very interesting paper, Haridas et al. have shown that patients with intraoperative floppy iris syndrome (IFIS) receiving tamsulosin or doxazosin differ in terms of morbidity rates [1]. Among 2,785 cataract operations performed in 2,028 patients, the authors identified 52 (1.9 %) cases treated with tamsulosin and 109 (3.9 %) cases in which doxazosin was administered. They compared morbidity rates between these two groups. In our opinion, however, some aspects of this study need to be discussed. In their retrospective analysis, the authors found at least one IFIS feature in 17 out of 106 eyes (16 %) from the doxazosin group and in 25 out of 52 eyes (48 %) from the tamsulosin group. Alpha-1 antagonists, used in the symptomatic treatment of benign prostatic hyperplasia, may increase the surgical difficulties and risk of iris damage, corneal edema, posterior or anterior capsule rupture, and postoperative increase in intraocular pressure [2–4]. Nevertheless, analysis of data expressed as percentages can be misleading and provide false information on the prevalence of IFIS and expected intraoperative morbidity rate. In Table 1 of their paper, Haridas et al. presented data on the size of the pupil and status of the iris in the tamsulosin and doxazosin groups [1]. However, the prevalence of various abnormalities (large or small pupil, iris prolapse, etc.) was expressed as a percentage of IFIS cases in a given group, i.e. per 25 and 17 eyes in tamsulosin and doxazosin group, respectively. In our opinion, however, the prevalence should be rather expressed per the whole group administered a given agent, i.e. per 52 and 106 eyes of patients treated with tamsulosin and doxazosin, respectively. Only in this way can we estimate the potential risk of intraoperative complications in patients treated with α-1 antagonists. Furthermore, it should be noted that expressing seven cases of intraoperative complications in the tamsulosin group as 13.5 % (7 out of 52 eyes) suggests that such morbidity can be expected in patients subjected to cataract surgeries. This is not true, as intraoperative complications documented in the tamsulosin IFIS group (iris damage – 5 cases, anterior capsule rupture – 1 case, corneal edema – 1 case) corresponded to only 0.3 % of all 2,785 operated eyes, the average rate of cataract complications in non-IFIS patients. Takmaz analyzed a group of 858 operated eyes and identified intraoperative complications in 6 eyes of patients who were treated with tamsulosin [8]. However, he emphasized the lack of significant differences in the morbidity rates of tamsulosin-treated patients with and without IFIS (p = 0.245). According to Haridas et al., patients treated with tamsulosin differed significantly from the controls in terms of the morbidity rates (13.5 %, i.e. 7 out of 52 eyes vs. 3.3 %, i.e. 5 out of 150 eyes; p = 0.014) [1]. However, we postulate that statistical analyses are not justified in the case of such a large disproportion in group size. Furthermore, this analysis was not adjusted for surgeon’s experience and other intraoperative factors. Table 1 Studies reporting the rate of intraoperative floppy iris syndrome (IFIS) complications The exact data on the type and prevalence of intraoperative complications is missing in available literature. (Table 1) Chang et al. spoke to the intraoperative use of retractors in five cases but did not provide any data on the percentage of postoperative iris damage in patients with IFIS [2]. In turn, the report by Oshika et al. not only lacks any data on postoperative morbidity rates but does not provide any information about intraoperative strategies of performing cataract phacoemulsification in patients with IFIS [6]. Concluding: Although the use of α-1 antagonists, especially tamsulosin, can constitute a potential risk of intraoperative complications in cataract surgery, such complications occur sporadically, and therefore, the morbidity rates should be presented in a uniform manner in order to avoid their inadvertent overestimation.

Prevention of intraoperative complications during stapled excision of rectal mucosal prolapse

Submucosal saline injection and triple purse-string are reported to prevent peritoneal stitching and mucosal pocketing, two intraoperative complications in patients who undergo a stapled transanal excision for internal mucosal prolapse causing obstructed defaecation.