Routine Postoperative Visits Research Articles

Posterior iliac crest pain after posterolateral fusion with or without iliac crest graft harvest

Background context Considerable debate exists regarding the incidence of persistent pain from the iliac crest bone graft (ICBG) harvest site. Different study designs have led to a variety of reported rates. Purpose The purpose of this study was to determine the incidence and severity of bone graft site pain after iliac crest harvest. Study design Cross-sectional. Patient sample One hundred and twelve patients, who had a posterior lumbar fusion, seen at a tertiary spine center for a routine postoperative visit. Outcome measures Numeric rating scales (0–10) for pain over lower back, right, and left posterior iliac crests. Methods An independent investigator, not directly involved in the care of the patient and unaware of the type of bone graft used in the fusion, examined the patient for tenderness over the surgical site as well as the left and right posterior iliac crest. After the examination, data on the source of grafting material, complications during harvest, and backfilling of the graft site defect were collected from the medical records. The patients were then classified as to whether ICBG was harvested or not. Chi-square test was used to determine any difference in the proportion of iliac crest pain between the bone graft group and no bone graft group. Correlations between body mass index (BMI), time since surgery, and the incidence and severity of bone graft site pain were also determined. Results There were 72 women and 40 men with a mean age of 56.6 years (range, 16–84). Mean follow-up was 41 months (range, 6–211 months) with a median of 25 months. Iliac crest bone graft was harvested in 53 (47.3%) patients through the midline incision used for lumbar fusion. In 59 patients (52.7%), recombinant human bone morphogenetic protein-2 was used with no graft harvest. There was no statistically significant difference in the proportion of patients complaining of tenderness over both or either iliac crest between the two groups. Only 10 patients had pain over the same crest from which the graft was harvested. No correlations between number of levels fused, levels fused, BMI, length of follow-up, and the incidence and severity of bone graft site pain were seen. Conclusions The results of this study highlight the difficulty in differentiating pain originating from the graft site versus residual low back pain. The incidence of pain over the iliac crest was similar in patients in which iliac crest was harvested and those in which no graft was harvested.

Should patients routinely be visited by the anaesthetist once they have left the recovery area?

An anaesthetic preoperative assessment for all patients is the standard of care in UK hospitals, but guidance from the Royal College of Anaesthetists (Curran and Rowbotham, 2009) states that a postoperative visit by an anaesthetist is only recommended in certain circumstances, such as those patients graded American Society of Anesthesiologists (ASA) physical status 3, 4 or 5, or patients discharged from recovery with invasive monitoring in situ. There are a number of potential advantages of a routine postoperative visit by the anaesthetist, so why is this not performed? This article examines the arguments for and against a routine postoperative visit by an anaesthetist.

Outcomes of Tension-Free Vaginal Tape in Women With Intrinsic Sphincter Deficiency With or Without Urethral Hypermobility

In Brief Objective: The objective of this study was to evaluate the outcomes of tension-free vaginal tape (TVT) for the treatment of female urodynamic stress incontinence (USI) resulting from intrinsic sphincter deficiency (ISD) in patients with and without urethral hypermobility. Methods: A 2-center cohort study of 175 consecutive women treated with TVT for USI with ISD over a 30-month period was performed. One hundred twenty-four (71%) women had coexisting urethral hypermobility and 51 (29%) had fixed urethrae. Concurrent surgical repairs were performed as required. Outcome data were collected at routine postoperative visits. Office and hospital records were reviewed to determine differences in patient characteristics, intraoperative findings, and surgical outcomes. The study was powered to detect a 20% difference in cure rates between the 2 groups. Results: Women with fixed urethrae were older than those with urethral hypermobility (72.3 versus 61.3 years, P < 0.0001) and were less likely to undergo concurrent anterior colporrhaphy (12% versus 37%, P = 0.0009). They were more likely to undergo concurrent posterior colporrhaphy (43% versus 20%, P = 0.0018). Cure rates among patients with fixed versus hypermobile urethrae were similar (83% and 86%, respectively, P = 0.61). Complication rates were similarly low in both groups (5.9% versus 5.6% for fixed and hypermobile urethrae, respectively). Postoperative voiding dysfunction occurred at similar rates in both groups (P = 0.96). Conclusion: TVT is a highly effective treatment among patients with USI resulting from ISD with comparable cure rates in patients with or without urethral hypermobility. Tension-free vaginal tape is an effective treatment for intrinsic sphincter deficiency, regardless of preoperative urethral mobility (Q-tip) status.

Tension-free vaginal tape (TVT) for treatment of stress urinary incontinence in women with low-pressure urethra

Objective:To assess the results of TVT in patients with urinary stress incontinence, urethral hypermobility, and low-pressure urethra. Study design:We retrospectively analysed 265 consecutive women who underwent a TVT procedure for urodynamic stress urinary incontinence over a 31-month period. Women were divided into two groups depending on their preoperative maximum urethral closure pressure (MUCP). Group 1 (61 women with MUCP ≤20cm H2O) were compared with 204 women (group 2) with a MUCP >20cm H2O. Subjective and objective outcome data were assessed from routine postoperative visits. Office and hospital records were reviewed to check patients’ characteristics, intraoperative findings, and surgical outcomes. Results:Women with low-pressure urethra were older than those with MUCP >20cm H2O; they were more likely to have had a hysterectomy or anti-incontinence surgery. The mean duration of follow-up was 31 (±11) months. Cure rates among patients with low- or normal-pressure urethra were similar (77% and 86%, P=0.70). Nevertheless, the former were more likely to complain of voiding dysfunction.Conclusion: TVT is a highly effective treatment even in women with intrinsic sphincter deficiency.

The Lap-Band system in a North American population.

European and Australian results with laparoscopic adjustable gastric banding (LAGB) using the Lap-Band (Inamed Health, Santa Barbara, CA) have been impressive, with over 100,000 procedures completed at this writing. However, prior to U.S. FDA approval in June 2001, U.S. patients had to travel out of the U.S. for this procedure. This study reports on a series of U.S. patients who requested off-shore referral for LAGB placement. 105 U.S. patients were implanted with the Lap-Band System in Mexico by one surgeon in a private practice. 70% were implanted with the perigastric approach, while the final 30% were implanted using the pars flaccida approach. Routine postoperative visits, including band adjustments, were completed in a private U.S. clinic where medical staff performed frequent small adjustments as necessary to optimize results. Data were collected from concurrent and retrospective chart reviews and from telephone interviews. Summary statistics provided for baseline measures included mean +/- standard deviation. Postoperative measures of weight loss included mean +/- standard error. Weight loss results were comparable to international results: 61% EWL at 12 months (n=50), 75% EWL at 24 months (n=37), 72% EWL at 36 months (n=24), and 60% EWL at 48 months (n=7). There were few major complications. Attention to patient management is essential to success, and this study found that appropriately-managed U.S. LAGB patients can be as successful as their international counterparts. Frequent follow-up delivered by a bariatric team with easy access to band adjustments is essential.

Tension-free vaginal tape: outcomes among women with primary versus recurrent stress urinary incontinence

OBJECTIVE: To evaluate the outcomes of tension-free vaginal tape in the treatment of primary versus recurrent genuine stress urinary incontinence. METHODS: A retrospective, multicenter study of 245 consecutive women who were treated with tension-free vaginal tape for genuine stress urinary incontinence (157 for primary and 88 for recurrent genuine stress urinary incontinence) over a 27-month period was performed. Concurrent surgical repairs were performed as required. Subjective and objective outcome data were assessed from routine postoperative visits. Office and hospital records were reviewed to determine patient characteristics, intraoperative findings, and surgical outcomes. RESULTS: Women with recurrent genuine stress urinary incontinence were older (mean age 64.6 versus 59.4 years, P = .004) than those with primary incontinence; they were less likely to have an intact uterus (22.7% versus 66.9%, P < .001), and were more likely to have intrinsic sphincter deficiency (70.5% versus 47.1%, P < .001). The mean duration of follow-up was 38 (±16) weeks. Cure rates among patients with recurrent versus primary genuine stress urinary incontinence were similar (85% and 87%, respectively, P = .23). Complication rates were similarly low in both groups (4.5% versus 7.6% for recurrent and primary genuine stress urinary incontinence, respectively, P = .35). Postoperative voiding dysfunction occurred at low rates in both groups. CONCLUSION: Tension-free vaginal tape is a highly effective treatment among patients with recurrent stress incontinence, with outcomes comparable with those among patients with primary incontinence.

Tension-Free Vaginal Tape

In Brief OBJECTIVE To evaluate the outcomes of tension-free vaginal tape in the treatment of primary versus recurrent genuine stress urinary incontinence. METHODS A retrospective, multicenter study of 245 consecutive women who were treated with tension-free vaginal tape for genuine stress urinary incontinence (157 for primary and 88 for recurrent genuine stress urinary incontinence) over a 27-month period was performed. Concurrent surgical repairs were performed as required. Subjective and objective outcome data were assessed from routine postoperative visits. Office and hospital records were reviewed to determine patient characteristics, intraoperative findings, and surgical outcomes. RESULTS Women with recurrent genuine stress urinary incontinence were older (mean age 64.6 versus 59.4 years, P = .004) than those with primary incontinence; they were less likely to have an intact uterus (22.7% versus 66.9%, P < .001), and were more likely to have intrinsic sphincter deficiency (70.5% versus 47.1%, P < .001). The mean duration of follow-up was 38 (±16) weeks. Cure rates among patients with recurrent versus primary genuine stress urinary incontinence were similar (85% and 87%, respectively, P = .23). Complication rates were similarly low in both groups (4.5% versus 7.6% for recurrent and primary genuine stress urinary incontinence, respectively, P = .35). Postoperative voiding dysfunction occurred at low rates in both groups. CONCLUSION Tension-free vaginal tape is a highly effective treatment among patients with recurrent stress incontinence, with outcomes comparable with those among patients with primary incontinence. Tension-free vaginal tape is an effective treatment for patients with recurrent stress urinary incontinence, including those with intrinsic sphincter deficiency or prolapse.

The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients.

Transesophageal echocardiography (TEE) is an invaluable intraoperative diagnostic monitor that is considered to be relatively safe and noninvasive. Insertion and manipulation of the TEE probe, however, may cause oropharyngeal, esophageal, or gastric trauma. We report the incidence of intraoperative TEE-associated complications in a single-center series of 7200 adult cardiac surgical patients. Information related to intraoperative TEE-associated complications was obtained retrospectively from the intraoperative TEE data form, routine postoperative visits, and cardiac surgical morbidity and mortality data. The overall incidences of TEE-associated morbidity and mortality in the study population were 0.2% and 0%, respectively. The most common TEE-associated complication was severe odynophagia, which occurred in 0.1% of the study population. Other complications included dental injury (0.03%), endotracheal tube malpositioning (0.03%), upper gastrointestinal hemorrhage (0.03%), and esophageal perforation (0.01%). TEE probe insertion was unsuccessful or contraindicated in 0.18% and 0.5% of the study population, respectively. These data suggest that intraoperative TEE is a relatively safe diagnostic monitor for the management of cardiac surgical patients. The overall morbidity (0.2%) and mortality (0%) rates of intraoperative transesophageal echocardiography (TEE) were determined in a retrospective case series of 7200 adult, anesthetized cardiac surgical patients. The most common source of TEE-associated morbidity was odynophagia (0.1%), which resolved with conservative management. These results suggest that TEE is a safe diagnostic tool for the management of cardiac surgical patients.

Transvaginal therapy of genuine stress incontinence

Two minimally invasive techniques for treatment of genuine stress incontinence, a transvaginal retropubic urethropexy and a transvaginal sling, using Cooper’s ligament as the anchoring structure, are reported along with the early results. These surgeries can be done easily in conjunction with vaginal reconstructive procedures. Twenty-seven women were operated on between October 1998 and September 1999. Seventeen women underwent the transvaginal retropubic urethropexy for genuine stress incontinence, whereas 10 women underwent the transvaginal sling for genuine stress incontinence with maximal urethral closure pressures less than 20 cm H 2O. Postoperative urodynamics were done routinely at 4 months. Subjective follow-up was by routine postoperative visits or telephone survey. The mean follow-up of the retropubic urethropexy group was 6.5 months (range 1 to 12). Of these 17 women, 16 (94%) had no stress incontinence. Seven of 14 patients (50%) resolved their urge incontinence also. The mean follow-up of the transvaginal sling group was 2.8 months (range 1 to 4.5). Of the 10 patients in this group, 7 (70%) were cured of their stress incontinence. One patient in each group underwent only the anti-incontinence procedure without concomitant vaginal reconstructive procedures; both of these women were dry. Additional follow-up is required to see if these minimally invasive techniques produce successful results in the long term.

Fast-track recovery of the coronary bypass patient

A new approach termed “fast-track recovery” was undertaken at both the Baystate Medical Center and Hartford Hospital. The fast-track protocol involves the following principles: (1) preoperative education; (2) early extubation; (3) methylprednisolone sodium succinate before bypass followed by dexamethasone for 24 hours postoperatively; (4) prophylactic digitalization, metoclopramide HCl, docusate sodium, and ranitidine HCl; (5) accelerated rehabilitation; (6) early discharge; (7) a dedicated fast-track coordinator to perform both daily telephone contact and a 1-week postoperative examination; and (8) a routine 1-month postoperative visit with a PA or MD. To evaluate the effects of this approach on patient care, a retrospective 1-year analysis was undertaken in both institutions with all coronary artery bypass grafting patients compared in a consecutive manner before the origin of the fast-track protocol and subsequent to its beginning. There were 280 patients in the fast-track and 282 in the non-fast-track group. The two groups were not significantly different except inexplicably there was a lower ejection fraction in the fast-track group and a longer cross-clamp time. Postoparatively, the mean time to extubation decreased from 22.1 to 15.4 hours, and peak weight gain decreased from 2.8 to 1.6 kg from the non-fast-track to the fast-track group ( p < 0.01). This was accompanied by significant ( p < 0.001) decreases in intensive care unit duration from 2.4 to 1.9 days and in postoperative length of stay from 8.3 to 6.8 days from the non-fast-track to the fast-track group. There was no increase in morbidity or mortality associated with the fast-track protocol either early or late. Thirty-day hospital readmission was not significantly different between the two groups. Fast-track methodology is effective, and we routinely employ this approach for all patients undergoing cardiopulmonary bypass.