Significant Operative Complications Research Articles

Partial cricotracheal resection with primary anastomosis for pediatric laryngotracheal stenosis

Severe laryngotracheal stenosis (LTS) in the pediatric age group has been traditionally treated by laryngotracheoplasty procedures. This approach may be complex and multistaged. High success rates have been reported in adults with severe LTS who underwent partial resection of the cricoid and primary thyrotracheal anastomosis. However, this procedure has not been widely reported in infants and children. Since November 1993, 38 patients with grade III or IV subglottic stenosis were treated with partial cricotracheal resection (CTR) and primary anastomosis. In some patients a posterior cricoid split or partial arytenoidectomy was performed as well. The preoperative evaluation, surgical techniques, and postoperative care are described. There were no significant operative complications or deaths. Thirty-three patients were decannulated after a single open surgical procedure. Our results as well as those of previous series suggest that CTR with primary anastomosis is a relatively safe and effective procedure in infants and children with severe LTS.

Laparoscopic oophorectomy: an emerging option for the management of breast cancer

The introduction of laparoscopy into surgical practice has stimulated interest in laparoscopic oophorectomy, particularly in view of the cost and morbidity of alternative therapies. Since 1993, the QEH Breast Unit has employed laparoscopic oophorectomy in selected cases of breast cancer. In the 36 months to May 1996, 28 premenopausal breast cancer patients underwent oophorectomy, with 27 having the procedure completed laparoscopically. The procedure was performed as adjuvant therapy in 25 patients; 3 had known metastatic disease. For laparoscopic oophorectomy the median inpatient stay was 2 days (range 1–4), and the operative time was a median of 34 min (range 25–53). No significant operative complications occurred, but 1 patient was converted to open surgery due to the presence of dense peritoneal adhesions. Laparoscopic oophorectomy is feasible, can be performed safely with minimal morbidity, and is cost-effective.

Location of ferromagnetic foreign bodies by the PF-02 ferroprobe pole indicator

UDC 615.47.03:616-003.6-089.878 The Institute for Physics of Metals, Ural Division, Russian Academy of Sciences has a leading place in the Russian Federation in the development of medical ferroprobe pole indicators. Several models of ferroprobe pole indicators have been developed at the Institute over the last two decades, including FP-2, PFT-2, PF-1, and PF-01 devices [3, 7, 8, 10]. Besides, various comprehensive methods of preoperative and operative ferroprobe diagnosis were developed for general and ophthalmological surgery, boundary location of ferromagnetic foreign body in orbital cavity, etc. [2, 4, 5, 7]. These methods have been successfully tested in clinics and hospitals of Ekaterinburg, Moscow, and St. Petersburg. In the present state of surgery, it is not enough to merely remove the foreign body, but it is important to remove it with minimum possible damage to surrounding tissues. Therefore, maximum accuracy of foreign body location during the preoperative period and surgery itself is very important. In technical terms, this can be achieved by increasing the sensitivity of ferroprobe pole sensors, by eliminating false signals caused by a uniform static geomagnetic field and low quality of magnetosensitive elements of the ferroprobe sensor (FS) [1, 3, 7], and by improving the circuitry base of the ferroprobe pole indicator. Consider the problem of increasing the sensitivity of a ferroprobe pole sensor in more detail. Theoretically, the sensitivi- ty of a ferroprobe pole sensor can be increased by decreasing the dysbalane between the magnetosensitive elements of the sensor or by increasing the gain of the electronic unit of the device. However, in practice, maximal sensitivity of a pole indicator is limited by the magnetic environment in the operating room (influence of devices, equipment, operating table, light sources, construction elements, etc.). Because the foreign body signal amplitude decreases as the fourth power of the distance from the free end of the probe, the problem of noise proofing places substantial limitations on further increase of the sensitivity of ferroprobe pole indicators. It should be noted that the sensitivity to gradient of static magnetic field strength of the PF-01 ferroprobe pole indicator, which is widely used in medical practice, reaches 4 mOe/cm full scale (0.0032 A/cm 2 in SI units). This allows sufficiently accurate preoperative location of ferromagnetic foreign bodies in living tissues, although if the depth of penetration of the foreign body exceeds 50 to 70 ram, such sensitivity proves insufficient for accurate preoperative location of the foreign body. Therefore, it seems that further increase in the accuracy of location of a ferromagnetic foreign body by significant increase in the sensitivity of the pole indicator is not a very promising approach to the problem. Consider the problem of increase of the accuracy of location of a ferromagnetic foreign body by means of elimination of false signals. Presently available models of pole indicators have a substantial disadvantage because variation of spatial orientation of the FS, e.g., rotation about its longitudinal (measuring) axis or slewing by 180 ~ induces a false signal which simulates the presence of an inhomogeneous magnetic field (i.e., the presence of a ferromagnetic foreign body), whereas the magnetic field is homogeneous (ferromagnetic foreign body is absent). These effects are due to: a) nonparallel orientation of magnetic axes (cores) of the FS magnetosensitive elements; b) lack of identity between the transformation coefficients of the FS magnetosensitive elements. In medical practice, a false signal may cause an unnecessary surgical incision which may have significant operative and postoperative complications. Both methodological and technical measures can be taken to eliminate or substantially reduce false signals. A ferroprobe pole sensor is considered as suitable for practical purpose if the amplitude of false signal measured at Institute for Physics of Metals, Ural Division, Russian Academy of Sciences. Ural State Medical Academy, Ekaterinburg. Translated from Meditsinskaya Tekhnika, No. 6, pp. 28-33, November-December, 1996. Original article submitted November 16, 1995. 0006-3398/96/3006-0337515.00 9 Plenum Publishing Corporation 337

Laparoscopic myomectomy in African-American women

Study Objective. To evaluate the effectiveness of laparoscopic myomectomy in an ethnic group with a statistically increased frequency of uterine leiomyomata. Design. Retrospective chart review. Setting. Private practice of one surgeon, and Department of Obstetrics and Gynecology, Rush Medical College, Chicago, Illinois. Patients. Forty-one consecutive African-American women who underwent laparoscopic myomectomy and were followed for 12 to 26 months. Interventions. The women received a modified protocol for gonadotropin-releasing hormone agonist treatment before laparoscopic surgery. Laparoscopic myomectomies were performed under general anesthesia using energy sources of monopolar and bipolar electrosurgery and ultrasonic coagulation-cutting (harmonic scalpel). Measurements and Main Results. Seventy percent (70%, 29 women) of procedures were completed on an outpatient basis. Twelve patients were hospitalized for an average of 1.3 days. No significant operative or postoperative complications occurred, and none of the women required blood transfusions or readmission. The conversion rate was zero. Forty patients (91%) reported complete resolution or significant reduction of their symptoms. Conclusions. Outpatient laparoscopic myomectomy is safe and effective in African-American women with symptomatic uterine leiomyomata of 20 weeks' size or less.

Extracapsular cataract extraction after vitrectomy

Objective: To ascertain the reliability, safety, and effectiveness of extracapsular cataract extraction (without the use of pars plana infusion) in eyes that have had vitrectomy.Setting: The Manchester Royal Eye Hospital.Methods: A retrospective analysis of surgical and postsurgical complications and visual acuity change in 41 patients who had one or more vitreoretinal procedures, followed by extracapsular cataract extraction and intraocular lens implantation at a subsequent date.Results: No significant operative complications were encountered using an extracapsular technique without pars plana infusion. Thirty eyes (73.2%) had a significant increase in visual acuity, 10 (24.4%) did not change, and 1 worsened.Conclusions: A modified form of extracapsular extraction, with control of intraocular fluid flow but without the use of a pars plana infusion, is safe and effective in post-vitrectomy eyes.

Surgical Management of Hyperparathyroidism at an Air Force Medical Center

A critical determinant of successful neck exploration for primary hyperparathyroidism (HPT) is the experience of the surgeon. Results of 17 patients treated surgically for HPT were reviewed to compare results at our medical center with results of large series reported from established national centers. Preoperative laboratory evaluation of 15 patients with surgically proven HPT (solitary adenoma, 14; diffuse hyperplasia, 1) included: mean serum calcium (Ca) 10.9 mg/dl +/- 0.79 and mean serum chloride/phosphate ratio 39 mg/dl +/- 7.9. Serum parathyroid hormone (PTH) was elevated in all patients. Seven neck ultrasounds were performed with a positive predictive value of 42%. No significant operative complications occurred. Mean postoperative serum Ca was 8.34 mg/dl +/- 0.75. One patient had asymptomatic hypocalcemia (Ca = 6.5 mg/dl). Follow-up in 11 patients (65%) at a mean of 8.6 months revealed no evidence of recurrence in these patients. In our experience, proper patient selection and careful surgical technique within established principles for neck exploration and parathyroidectomy lead to excellent results despite the size of the medical center. Patient selection is based on serum Ca, PTH, and chloride/phosphate ratio. Preoperative imaging studies did not appear to be of benefit in the small study reported here.

Intrahepatic hepatocyte transplantation following subtotal hepatectomy in the recipient: A possible model in the treatment of hepatic enzyme deficiency

Orthotopic liver transplantation as treatment for hereditary enzyme deficiences in the absence of cirrhosis suffers from significant operative risks, complications, and donor shortages. Transplantation of isolated hepatocytes (HTX) may offer opportunities for the treatment of these diseases and retain the recipient liver. Hepatocytes transplanted into the portal vein, spleen, or omentum lack and ideal growing environment for cell proliferation and maintenance. Therefore, we investigated a method combining 75% recipient hepatectomy with direct injection of hepatocytes into the remaining 25% of liver parenchyma to provide proliferative stimuli and a stable environment during and following liver regeneration. Recipient Gunn rats (glucuronyltransferase deficiency and hyperbilirubinemia) underwent hepatectomy before HTX by direct injection of 10 7 isolated hepatocytes into the remaining parenchyma. Inbred male Wistar and Gunn rats were used as normal and control hepatocyte donors and saline injection served as a sham transplant control. Isolation of donor hepatocytes was performed with a two-step collagenase digestive method (Seglen) with cell viability of 85% to 95%. Liver regeneration was complete by 2 weeks posttransplant. Four weeks following HTX, total serum billirubin and qualitative bile analysis were performed. A significant decrease in total serum bilirubin levels was observed in Gunn rats receiving Wistar hepatocytes compared with those receiving Gunn hepatocytes and saline control. Bile analysis from HTX rats demonstrated a normal pattern containing bilirubin monoglucuronides and diglucuronides (conjugated bilirubin) in the rats receiving Wistar hepatocytes, whereas the control group receiving Gunn hepatocytes or saline injection demonstrated only unconjugated bilirubin. No differences in histological appearance were noted between groups. We conclude that partial hepatectomy may provide the required stimulus for proliferation of transplanted hepatocytes and the liver may provide the necessary environment for optimal hepatocyte function and bile excretion following transplantation.

Management strategies in resection for hilar cholangiocarcinoma.

Between 1960 and 1990, resection was performed in 23 of 122 patients who underwent surgical treatment for hilar cholangiocarcinoma. Local excision of the lesion alone was performed in 10 cases (43%). Hepatic resection for tumor extending to the secondary bile ducts or hepatic parenchyma was performed in 13 cases (57%): extended right hepatectomy (3), right hepatectomy (1), extended left hepatectomy (6), left hepatectomy (2), and left lobectectomy (1). In three other cases, resection by total hepatectomy and liver transplantation was performed, but these were not included in the analysis of results for resection. Significant operative complications occurred in only two cases (8.7%), and the operative mortality rate was zero. In four cases, complete excision of the tumor could not be achieved macroscopically (macroscopic curative resection rate 19/122; 15.6%). In nine cases, the margins of the resected specimens were free from tumor on histologic examination (microscopic curative resection rate, 9/122; 7.4%). In 10 cases, the resection margins were found to contain tumor on histologic examination. The overall survival rate was 87% at 1 year, 63% at 2 years, and 25% at 3 years (median survival, 24 months). The survival and freedom from recurrence rates for patients with free resection margins was superior to that for patients with involved resection margins or residual macroscopic disease. A potentially curative resection, with histologically negative margins and no recurrence to date, was achieved in seven patients using the following procedures: local excision for two type I lesions; left hepatectomy plus excision of segment 1 for two type IIIb lesions and one type IV lesion; right hepatectomy and right hepatectomy plus excision of segment 1 for two type IIIa lesions. These results indicate that improved survival in hilar cholangiocarcinoma can be achieved by resection, with minimal morbidity and zero mortality rates, if histologically free resection margins are obtained. To achieve this, we recommend the following procedures for each type of lesion, based on our experience and on anatomic considerations: local excision for type I; local excision plus resection of segment 1 for type II; local excision, resection of segment 1, and right or left hepatectomy for types IIIa and b; hepatectomy plus liver transplantation for type IV.

Transverse carpal ligament reconstruction in surgery for carpal tunnel syndrome: A new technique

We present a two-year follow-up of a technique to reconstruct the transverse carpal ligament in surgery for carpal tunnel syndrome. The transverse carpal ligament is exposed through a four to five centimeter palmar incision in line with the axis of the ring finger. The ligament is divided in step-wise fashion, creating a distal radially-based flap and a proximal ulnarly-based flap. The apices of these flaps are approximated, lengthening the ligament six to ten millimeters. All seventy-three patients (one hundred-four hands) reported substantial improvement with 93% having complete resolution of symptoms. Ninety-seven percent returned to work (average disability, two months). There were no recurrences or significant operative complications. In those with unilateral reconstruction (60%), there was no diminution in grip strength (p less than 0.05). This technique of transverse carpal ligament reconstruction stabilizes the transverse carpal arch, provides protection to the median nerve, prevents bowstringing of the flexor tendons, and maximizes postoperative grip strength.

Laser lingual tonsillectomy.

Diseases of the lingual tonsils are generally overlooked in both clinical practice and medical literature. Infections of the lingual tonsils are usually treated medically, although in patients with symptomatic chronic inflammation or hyperplasia of the lingual tonsils, surgical intervention may be indicated. Eighty-two patients with benign inflammatory problems of the lingual tonsils, who were not improved by medical management, underwent laser lingual tonsillectomy at four different medical centers, between 1984 and 1987. The procedure was tolerated well by all of the patients, with no significant operative complications. Short- and long-term results were satisfactory. Laser surgery is an effective method for the treatment of benign hyperplastic and inflammatory diseases of the lingual tonsils.

Operative complications of tracheoesophageal puncture.

Tracheoesophageal puncture is not a complex procedure; nevertheless, significant complications are possible. In the last four years we have performed this procedure in 47 patients. Seven of them (15%) sustained significant complications related to the procedure. These included three cases of mediastinitis and sepsis, although surgical drainage was not required. Three other patients developed cellulitis of the trachea and root of the neck, centered around the tract through the party wall; one patient suffered a fracture of the cervical spine. Eight lesser complications also occurred. Tracheoesophageal puncture's simplicity and effectiveness surpass those of any other surgical procedure for voice restoration. However, our experience demonstrates that, as with any operation, the technique may be associated with significant operative complications.