Single-institution Retrospective Case Series Research Articles

Identifying the Rate-Limiting Step in Total Laparoscopic Hysterectomy in a Training Hospital.

To identify the lengthiest step of total laparoscopic hysterectomy (TLH) in a teaching hospital and to determine which clinical factors affect the duration of this step. The University of Louisville Hospital. Single institution retrospective case series. This is a retrospective chart and video review that included 135 benign, elective TLHs performed at The University of Louisville. TLH was divided into 5 steps: (1) insertion of laparoscopic ports and adhesiolysis to restore normal anatomy; (2) identification of the ureter and resection of adnexal structures to transection of the round ligament; (3) transection of the round ligament to transection of the uterine artery; (4) lateralization of the uterine vessel pedicle to completion of colpotomy; and (5) completion of vaginal cuff closure. The random intercept and slope model was used to identify the lengthiest step of TLH, and the backward elimination procedure was used to evaluate which clinical factors affected this step. Mean ± SD total length of TLH was 81 ± 30 min. The lengthiest step was colpotomy, with a mean duration of 24 ± 13 min. Uterine weight significantly increased the length of time required for colpotomy (p = .001). The primary energy source (ultrasonic scalpel vs monopolar hook) used to perform colpotomy did not influence the length of time (p = .539 vs p = .583). Uterine weight (p<.001) and adhesiolysis (p = .003) significantly increased the total time of TLH. At a teaching institution where surgeries are performed by residents and fellows, colpotomy is the lengthiest step of TLH and is influenced by uterine weight. This finding may reflect the training levels of the surgeons performing these cases and the learning curve associated with a challenging surgical skill. Further research should focus on simulation models and/or tools for colpotomy that may result in greater efficiency in the operating room.

P442: The value of SSR recordings in the assessment of autonomic nervous dysfunction in patients with sacral-pudendal impairment

P442: The value of SSR recordings in the assessment of autonomic nervous dysfunction in patients with sacral-pudendal impairment

PO-113: Activity and Safety of Vinorelbine in Adenoid Cystic Carcinoma: A Single Institution Retrospective Case Series

PO-113: Activity and Safety of Vinorelbine in Adenoid Cystic Carcinoma: A Single Institution Retrospective Case Series

Pancreaticoduodenectomy after Roux-en-Y gastric bypass: A single institution retrospective case series

Introduction: The unique challenges of pancreaticoduodenectomy in a patient with altered midgut anatomy secondary to Roux­en­Y gastric bypass are seldom discussed in surgical literature. We discuss two such cases at our institution, in light of experiences of other authors. Case Series: The two cases reported here are different from the majority of previously reported cases as remnant gastrectomy was not performed in either patient. However, one patient did receive a gastrostomy tube in the gastric remnant. The essential differences in existing literature are the removal of the gastric remnant in other reports versus a gastrojejunal anastomosis for remnant drainage in our cases, without any clear advantage in either case. Gastric remnant dissection increases operative time in contrast to gastrojejunal anastomosis, which is a nidus for complications postoperatively. With preservation of gastric remnant however, enteral feeding tube can be placed without manipulation of the altered anatomy, as the need arises. Conculsion: Gastric remnant removal is ideal in decreasing the complexity of pancreaticoduodenectomy by reducing the number of required anastomoses. However, there is an increase in operative time required for dissection of the remnant gastric pouch.

Laryngeal electromyography: a proposal for guidelines of the European Laryngological Society

Although recognized as a valuable diagnostic tool for more than 60 years, many laryngologists do not routinely use laryngeal electromyography (LEMG). This may be due to a persisting lack of agreement on methodology, interpretation, validity, and clinical application of LEMG. To achieve consensus in these fields, a laryngeal electromyography working group of European neurolaryngologic experts was formed in order to (1) evaluate guidelines for LEMG performance and (2) identify issues requiring further clarification. To obtain an overview of existing knowledge and research, English-language literature about LEMG was identified using Medline. Additionally, cited works not detected in the initial search were screened. Evidence-based recommendations for the performance and interpretation of LEMG and also for electrostimulation for functional evaluation were considered, as well as published reports based on expert opinion and single-institution retrospective case series. To assess the data obtained by this literature evaluation, the working group met five times and performed LEMG together on more than 20 patients. Subsequently, the results were presented and discussed at the 8th Congress of the European Laryngological Society in Vienna, Austria, September 1-4, 2010, and consensus was achieved in the following areas: (1) minimum requirements for the technical equipment required to perform and record LEMG; (2) best practical implementation of LEMG; (3) criteria for interpreting LEMG. Based on this consensus, prospective trials are planned to improve the quality of evidence guiding the proceedings of practitioners.

Correspondence

PURPOSE The purpose of this study was to describe the angiographic features and visual impact of macular fibrosis in patients with Coats disease. METHODS This is a single institution retrospective case series. Charts of patients diagnosed with Coats disease between 1973 and 2007 were reviewed. Data collected included patient demographics, treatment method, initial and final logarithm of the minimum angle of resolution visual acuity, photographic findings, angiographic characteristics, and anatomical outcome. RESULTS Forty-seven patients were identified with adequate imaging and posttreatment follow-up. Average age at presentation was 38 years (4-82 years). Average follow-up was 4.9 years (0-17 years). Macular fibrosis was identified in 11 patients (23%). At presentation, the average logarithm of the minimum angle of resolution visual acuity was as follows: all patients, 0.67; patients with macular fibrosis, 1.14; and patients without macular fibrosis, 0.50 (P = 0.01, 2-tailed Student's t-test). The average posttreatment logarithm of the minimum angle of resolution visual acuity was as follows: all patients, 0.78; patients with macular fibrosis, 0.97; and patients without macular fibrosis, 0.70 (P = 0.26). Macular fibrosis was associated with a pigmented spot at the point of apparent intraretinal vascular anastamosis. Fluorescein angiography showed leakage consistent with neovascularization that appeared to be intraretinal. CONCLUSION Macular fibrosis is a common finding in Coats disease, occurring in 23% of our patients. It may be a result of intraretinal neovascularization and is associated with a worse vision outcome.

MACULAR FIBROSIS IN COATS DISEASE

The purpose of this study was to describe the angiographic features and visual impact of macular fibrosis in patients with Coats disease. This is a single institution retrospective case series. Charts of patients diagnosed with Coats disease between 1973 and 2007 were reviewed. Data collected included patient demographics, treatment method, initial and final logarithm of the minimum angle of resolution visual acuity, photographic findings, angiographic characteristics, and anatomical outcome. Forty-seven patients were identified with adequate imaging and posttreatment follow-up. Average age at presentation was 38 years (4-82 years). Average follow-up was 4.9 years (0-17 years). Macular fibrosis was identified in 11 patients (23%). At presentation, the average logarithm of the minimum angle of resolution visual acuity was as follows: all patients, 0.67; patients with macular fibrosis, 1.14; and patients without macular fibrosis, 0.50 (P = 0.01, 2-tailed Student's t-test). The average posttreatment logarithm of the minimum angle of resolution visual acuity was as follows: all patients, 0.78; patients with macular fibrosis, 0.97; and patients without macular fibrosis, 0.70 (P = 0.26). Macular fibrosis was associated with a pigmented spot at the point of apparent intraretinal vascular anastamosis. Fluorescein angiography showed leakage consistent with neovascularization that appeared to be intraretinal. Macular fibrosis is a common finding in Coats disease, occurring in 23% of our patients. It may be a result of intraretinal neovascularization and is associated with a worse vision outcome.

Urinary Diversion

A consensus conference convened by the World Health Organization (WHO) and the Société Internationale d’Urologie (SIU) met to critically review reports of urinary diversion. The world literature on urinary diversion was identified through a Medline search. Evidence-based recommendations for urinary diversion were prepared with reference to a 4-point scale. Many level 3 and 4 citations, but very few level 2 and no level 1, were noted. This outcome supported the clinical practice pattern. Findings of >300 reviewed citations are summarized. Published reports on urinary diversion rely heavily on expert opinion and single-institution retrospective case series: (1) The frequency distribution of urinary diversions performed by the authors of this report in >7000 patients with cystectomy reflects the current status of urinary diversion after cystectomy for bladder cancer: neobladder, 47%; conduit, 33%; anal diversion, 10%; continent cutaneous diversion, 8%; incontinent cutaneous diversion, 2%; and others, 0.1%. (2) No randomized controlled studies have investigated quality of life (QOL) after radical cystectomy. Such studies are desirable but are probably difficult to conduct. Published evidence does not support an advantage of one type of reconstruction over the others with regard to QOL. An important proposed reason for this is that patients are subjected preoperatively to method-to-patient matching, and thus are prepared for disadvantages associated with different methods. (3) Simple end-to-side, freely refluxing ureterointestinal anastomosis to an afferent limb of a low-pressure orthotopic reconstruction, in combination with regular voiding and close follow-up, is the procedure that results in the lowest overall complication rate. The potential benefit of “conventional” antireflux procedures in combination with orthotopic reconstruction seems outweighed by the higher complication and reoperation rates. The need to prevent reflux in a continent cutaneous reservoir is not significantly debated, and this should be done. (4) Most reconstructive surgeons have abandoned the continent Kock ileal reservoir largely because of the significant complication rate associated with the intussuscepted nipple valve.

Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee

To determine the optimal evaluation and management of renal injuries by review of the world's English-language literature on the subject. A consensus conference convened by the World Health Organization and the Societé Internationale d'Urologie met to critically review reports of the diagnosis and treatment of renal trauma. The English-language literature about renal trauma was identified using Medline, and additional cited works not detected in the initial search obtained. Evidence-based recommendations for the diagnosis and management of renal trauma were made with reference to a five-point scale. There were many Level 3 and 4 citations, few Level 2, and one Level 1 which supported clinical practice patterns. Findings of nearly 200 reviewed citations are summarized. Published reports on renal trauma still rely heavily on expert opinion and single-institution retrospective case series. Prospective trials of the most significant issues, when possible, might improve the quality of evidence that dictates the behaviour of practitioners.