Time Of Initial Procedure Research Articles

Workflow and efficiency in MRI-based high-dose-rate brachytherapy for cervical cancer in a high-volume brachytherapy center

PurposeWe report the clinical workflow and time required for MRI-based image-guided brachytherapy (MR-IGBT) of cervical cancer patients in a high-volume brachytherapy center with 10 years of experiences to provide a practical guideline for implementing MR-IGBT into clinical use. Methods and MaterialsWe recorded the time and workflow of each procedure step within the 40 consecutive ring and tandem applicator fractions of MR-IGBT by our multidisciplinary team. We divided the entire procedure into four sections based on where the procedure was performed: (1) applicator insertion under sedation, (2) MR imaging, (3) planning, and (4) treatment delivery. In addition, we compared the current procedure time to the initial procedure time when first implementing MR-IGBT in 2007–2008 via a retrospective review. ResultsMean total procedure time was 149.3 min (SD 17.9, ranges 112–178). The multidisciplinary team included an anesthesia team, radiologist, radiation oncologist, nurses, radiation therapists, MRI technicians, dosimetrists, and physicists. The mean procedure time and ranges for each section (min) were as follows: (1) 56.2 (28.0–103.0), (2) 31.0 (19.0–70.0), (3) 44.3 (21.0–104.0), and (4) 17.8 (9.0–34.0). Under current setting, the combined mean procedure time for MR imaging and planning was 63.2 min. In comparison, the same procedure took 137.7 min in 2007–2008 period, which was significantly longer than the current workflow (p < 0.001). ConclusionsA skilled and dedicated multidisciplinary team is required for an efficient clinical workflow and delivery of MR-IGBT. Over the years, we have improved efficiency with clinical experience and continuous efforts in staff education.

Invited commentary

Invited commentary

Learning curves for transfemoral transcatheter aortic valve replacement in the PARTNER-I trial: Technical performance.

To assess technical performance learning curves of teams performing transfemoral transcatheter aortic valve replacement (TF-TAVR). TF-TAVR is a new procedure for treating severe aortic stenosis. The number of cases required for procedural efficiency is unknown. In the PARTNER-I trial, 1,521 patients underwent TF-TAVR from 4/2007-2/2012. Learning curve analysis of technical performance metrics was performed using institution-specific patient sequence number, interval between procedures, and institutional trial entry date. Learning curve characteristics were assessed using semi-parametric and parametric mixed-effects models. As patient sequence number increased, average procedure time decreased from 154 to 85 minutes (P < 0.0001), and fluoroscopy time from 28 to 20 minutes (P < 0.0001). Procedure time plateaued at an average of 83 minutes (range 52-140). Procedure time plateau was dynamic during the course of the trial, averaging 25 cases (range 21-52) by its end. The later institutions enrolled in the trial, the shorter the initial procedure time. During the trial, percutaneous rather than surgical access increased from 7.9% to 69%. Technical performance learning curves exist for TF-TAVR; procedural efficiency increased with experience, with concomitant decreases in radiation and contrast media exposure. The number of cases needed to achieve efficiency decreased progressively, with optimal procedural performance reached after approximately 25 cases for late-entering institutions. Knowledge and experience accumulated by early TF-TAVR institutions were disseminated, shortening the learning curve of late-entering institutions. Technological advances resulting from learning during the trial moved the field from initial conservative surgical cut-down to percutaneous access for most patients. © 2015 Wiley Periodicals, Inc.

Feasibility of Endoscopic Assessment and Treating to Target to Achieve Mucosal Healing in Ulcerative Colitis

Mucosal healing (MH) as a treatment target for ulcerative colitis is of growing interest because it is associated with improved clinical outcomes. However, the feasibility and probability of reaching MH in clinical practice is unknown. We therefore evaluated the feasibility of "treating to target" according to endoscopic findings to reach MH. All endoscopic outcomes of patients with ulcerative colitis followed in a single inflammatory bowel disease unit from 2011 to 2012 were reviewed and subsequent therapeutic management. Cumulative incidence of MH and histologic healing (HH) were estimated using a Kaplan-Meier method. A total of 60 patients underwent at least 2 consecutive endoscopic assessments, of whom 45 and 48 patients had endoscopic and histologic evidence of active disease, respectively. After a median follow-up of 76 weeks, 27 of 45 (60%) patients with endoscopic disease activity at baseline achieved MH and 24 (50%) of 48 patients with histologic disease activity at baseline had HH. The cumulative probabilities of MH were 26%, 52%, and 70% at 26, 52, and 76 weeks, respectively. The cumulative probabilities of HH at weeks 26, 52, and 76 from the time of initial procedure were 19%, 41%, and 57%, respectively. Any adjustment in medical therapy in case of persistent endoscopic activity was associated with both MH and HH. Repeated assessment of endoscopic disease activity with adjustment of medical therapy to the target of MH is feasible in clinical practice in patients with ulcerative colitis, and seems to be of benefit.

Effect of surgical techniques on long-term outcome in congenital pouch colon: A tertiary care centre experience.

The objective of the following study is to assess effect of a novel surgical technique on long-term outcome in operated cases of congenital pouch colon (CPC). We retrospectively analysed our surgical neonatal records from June 2002 to May 2012. Out of 477 cases of anorectal malformations, CPC was found in 73 (15%) cases. Out of 73 cases of CPC, 39 (53.4%) were complete pouch and 34 (46.6%) were incomplete. In addition to invertogram, an erect skiagram was done in all cases to confirm diagnosis. Patients were operated either by single stage pull-through or by staged procedure using conventional abdominoperineal (AP) pull-through or by our new hanging bowel technique. All patients were put on bowel management programme starting 1 month post-surgery until 5 years of life. Children presented to us at median age of 2.1 days. Mean weight at time of presentation was 2.74 kg. In our study, group median age at time of initial procedure was 2.7 days. In staged procedures definitive surgery was done after 6 months. Hospital stay in single stage procedure using the hanging bowel technique was 9.7 days while 17.4 days in conventional AP pull-through. Complication rate were high in conventional pull-through when compared to hanging bowel technique as shown by the significant P < 0.05. Our novel surgical technique for pull-through is suitable for both single stage as well as staged pull-through. Bowel enema programme should be an integral part of management of CPC.

Safety and Efficacy of Atrial Fibrillation Ablation in Young Patients.

Background: Outcome of catheter ablation of atrial fibrillation (AF) in young patients has not been widely reported. This study describes the safety and efficacy of radiofrequency catheter ablation (RFA) for atrial fibrillation in patients forty years or younger. Methods and Results: Forty consecutive patients who underwent fifty-two RFA procedures for symptomatic, drug-refractory paroxysmal or non-paroxysmal AF were included in the study. The mean (SD) age of the patients at time of initial procedure was 34.1 (5.6) years. Twenty-five (62.5%) patients had paroxysmal AF, 6 (15%) patients had persistent AF, and 9 (22.5%) patients had longstanding persistent AF. Procedural safety and efficacy were assessed based on patient status > 1 year after initial ablation procedure. After a mean (SD) follow-up of 3.8 (2.9) years, 25 (62.5%) patients were free of AF without antiarrhythmic drugs (AAD) and 40 (100%) patients experienced > 95% reduction of AF burden on or off AADs. No major complications or adverse events occurred during the study. Conclusions: Catheter ablation of AF is a favorable therapeutic option for patients 40 years or younger, resulting in high rates of procedural success with a low risk of major complications.

Emergency double-J stent insertion following uncomplicated Ureteroscopy: risk-factor analysis and recommendations

Emergency double-J (DJ) stenting following ″uncomplicated″ ureteroscopic (UURS) stone treatment is both morbid and costly. Our study aims at identifying those patients who are more likely to require such an extra procedure. Handling of this complication will also be highlighted. 319 cases of UURS cases were selected out of 903 patients, who were admitted for URS stone treatment at King Abdullah University Hospital during the period from May, 2003 to December, 2010. Thirty-eight of them (11.9%) had emergency post-URS DJ stenting within 24 hours of discharge. The medical records of all UURS cases were retrospectively reviewed. Comparison in demographic and stone-related variables was made using 2-paired t-test with P < 0.05. Operative findings of 38 stented patients were outlined. Significant risk factors for emergency stenting were noted in males with larger (> 1.5 cm) and proximal stones (38 stented vs. 281 unstented). Operative risk factors among the 38 patients were: initial procedure time > 45 minutes (42.1%), ureteral wall edema (21.1%), repeated access for stones > 1.5 cm (21.1%), impacted stone (10.5%) and ignored or missed stones/fragments (4.6%). The need for emergency DJ stenting following UURS stone treatment is not uncommon. The routine insertion is impractical and weakly-supported. With risk-factor stratification, selective and individualized DJ stenting policy is recommended.

Comparison of covered stents with detachable balloons for treatment of posttraumatic carotid-cavernous fistulas

Treatment of posttraumatic direct carotid-cavernous fistula (DCCF) with detachable balloons (DB) is associated with relatively low complete occlusion rates. We aimed to compare the angiographic and clinical results of treatment with covered stents with the results of treatment with DB. Thirty-four patients with posttraumatic DCCF were selected for treatment with DB (n=19, group A) or covered stents (n=15, group B). Data on the technical success, duration of initial procedure and hospital stay, initial and final angiographic results, mortality, morbidity and final clinical outcomes were collected and analyzed within 12months. DB deployment and covered stent placement were technically successful in all patients, except one patient in group B in whom the covered stent failed to navigate to the target DCCF. The initial angiographic results for the 33 patients with successful procedures showed complete occlusion in 16 patients in group A (84.2%; 95% confidence interval [CI]: 66%, 102%) and 11 patients in group B (78.6%; 95% CI: 54%, 103%; p>0.05). The 12-month angiographic results indicated complete occlusion in 12 patients in group A (63.2%; 95% CI: 39%, 87%) and 14 patients in group B (100%; p=0.013). The average initial procedure time was 120.0±17.76minutes in group A and 93.15±8.12minutes in group B (p<0.001). No significant differences were seen between the two groups in technical success, mortality, morbidity or final clinical outcomes. In this nonrandomized, prospective study of posttraumatic DCCF treatment, the 12-month angiographic results of treatment with covered stents was superior to that of BD.

Correction of Hypertelorbitism

Hypertelorbitism has been associated with a variety of congenital deformities. Appropriate timing for surgical correction remains controversial. We present our long-term experience of 33 patients with hypertelorbitism undergoing facial bipartition or orbital box osteotomy. Patients with hypertelorbitism treated with either facial bipartition or orbital box osteotomy and repositioning who had long-term follow-up were studied (n=33). Age at the time of first surgery, preoperative interdacryon distance, and immediate postoperative interdacryon distance were recorded. Relapse was determined on postoperative follow-up, and the need for secondary correction was noted. Physician satisfaction score (range, 0-4) was also assessed. Patients had a mean total follow-up of 14.0 years. With regard to age at the time of initial procedure, patients younger than 6 years were all noted to have relapse, and 83% underwent revision surgery. In patients 6 years or older, only 11% had relapse and required a second operation. Yet, satisfaction scores were similar (3.2 versus 3.5). With regard to the severity of hypertelorbitism, there was no relapse noted among patients with mild hypertelorbitism (interorbital distance [IOD], 30-34 mm). Among those with moderate hypertelorbitism (IOD, 35-40 mm), 29.4% developed relapse. By contrast, all patients with severe hypertelorbitism (IOD, >40 mm) were noted to have relapse requiring repeat correction. Satisfaction scores were similar (3.4 versus 3.3 versus 3.1). Relapse after surgery for hypertelorbitism is related to the age of the patient at correction and the preoperative severity. When possible, surgical repositioning of the orbits should be delayed until later childhood.

Comparison between Willis covered stent placement and coil embolization in the treatment of cranial internal carotid artery aneurysm: a nonrandomized prospective trial

Objective To evaluate the clinical results of Willis covered stent implantation and coil embolization in the treatment of cranial internal carotid artery (CICA) aneurysm. Methods Eighty-nine patients with CICA aneurysms were selected for treatment with Willis covered stents (n = 43, group A) or coil embolization (n =46, group B) according to the patients'will. Data on the technical success, initial procedure time and in-hospital interval, initial and final angiographic results, mortality, morbidity, and final clinical outcomes were collected and analyzed for the two groups at 6 months post-procedure. Results Endovascular covered stent placement and coil embolization were technically successful in all patients,except for one patient in group A. The initial angiographic results showed complete occlusion in 34 patients of group A (81%, 95% CI: 69%, 93% ) and 24 patients of group B (52%, 95% CI: 37%, 67% ) ( P ＜0. 05). The final angiographic results indicated complete occlusion in 39 patients of group A (39/41,95%,95% CI: 88%, 102% ) and 22 patients of group B (22/45,49%, 95% CI: 34%, 64% ,P ＜0. 01 ). The average procedure time was(103 ± 13)min in group A and (143 + 39) min in group B (P＜0. 01). No significant differences were seen between the two groups in technique success, mortality, morbidity, or final clinical outcomes. Conclusion In this nonrandomized, prospective trial, CICA aneurysm treatment with covered stents yielded midterm angiographic results that were superior to those of coil embolization. Key words: Intracranial aneurysm; Embolization, therapeutic; Coil; Stent; Case-control studies

Graft interposition colpocleisis, perineorrhaphy, and tension-free sling for pelvic organ prolapse and stress urinary incontinence in elderly patients

Study objective We sought to describe the outcome of combined colpocleisis, perineorrhaphy, and tension-free sling procedure for advanced uterovaginal prolapse and stress urinary incontinence in patients who are elderly and medically compromised. Design Prospective analysis. Setting University hospital. Patients Thirty-nine women were enrolled. Median age of patients was 82 years (76–94 years). Interventions All patients had advanced uterovaginal prolapse with perineal relaxation and incontinence and each wore a large pessary. Measurements and main results Median estimated blood loss was 42 mL (range 10–65 mL), median operating time was 58 minutes (range 45–76 minutes), and median hospital stay was 8 hours (range 0–3 days). Thirty procedures were accomplished without general anesthesia. Le Fort colpocleisis was reinforced with excessive mesh strips from the sling by placing mesh between anterior and posterior vaginal walls at the time of closure. No intraoperative complications occurred and none had postoperative voiding difficulty or significant discomfort. One patient required hospitalization for cardiac arrhythmias and 3 others for observation purposes only. Median follow-up has been 24 months. Follow-up physical examinations were performed for postoperative evaluation. One patient required reoperation for minor posterior compartment prolapse and another has started to show some apical prolapse again. Neither patient had a perineorrhaphy at the time of initial procedure. Two patients required some graft excision as a result of exposure from the side without any loss of support or discomfort. In all, 37 patients (37 of 39) are extremely pleased with the prolapse repair and 35 patients (35 of 39) report significant improvement of stress incontinence. Conclusion Concomitant severe pelvic organ relaxation and stress urinary incontinence can be surgically treated safely and rapidly using a tension-free sling and colpocleisis with perineorrhaphy under local anesthesia and sedation, thereby eliminating potential risks of general anesthesia and invasive surgery. A novel technique of graft interposition colpocleisis has been used.

Management of Raynaud's syndrome: our twenty-year experience

Purpose: 1) To review the long-term outcomes of a large group of patients who have undergone periarterial sympathectomy of the hand and 2) to describe the role of hand therapy in the evaluation and treatment of patients with Raynaud's syndrome. Method: We reviewed results on patients who had undergone periarterial sympathectomy (PAS) of the hand for recalcitrant ischemic pain, ulceration, and gangrene of digits from 1982 to the present. Data collection consisted of chart and operative review, and when possible follow-up telephone interview. Twenty-one (31 hands) had from two to 20 years of follow-up, ages at the time of initial procedure ranged from 21 to 87 years. Of these patients, three had suffered blunt trauma to the hand, four had mixed connective tissue disease, one had lupus, four had CREST (Calcinosis, Raynaud's phenomenon, esophageal involvement, sclerodactyly, and telangiectasia) or scleroderma, and the rest were idiopathic. Three main criteria—pain, ischemic ulceration, tissue loss (amputation)—were used to evaluate the success of treatment. We considered the initial procedure a success if the patient improved in one of the three main criteria. Patient satisfaction and changes in cold induced or Raynaud's attacks were also noted. The initial procedure was considered a failure if any of the criteria worsened or the patient required revision surgery or surgical amputation. When the result was rated as a failure, a critical review regarding the possible role of the surgical technique, disease progression, or both was considered. Not all Raynaud's syndrome patients require surgical intervention. A functional assessments algorithm aided our clinical decisionmaking regarding the choice of medical and/or surgical intervention. Evaluation baselines taken by the hand therapist included measurement of digital temperatures, cold recovery, tissue necrosis, sensibility, range of motion, and function. Repeat measures were used to evaluate the outcome of medical management or PAS. To complement medical management, the therapist discussed modification of risk factors, methods to reduce vasospastic episodes such as behavior and biofeedback techniques, and organized patient support groups. Results: Our first four patients had PAS of only the common volar vessels. To meet one of the three main criteria, all subsequent cases had PAS of the entire palmar arch, common volar digital arteries beyond the bifurcation into the digit, ulnar and radial artery. When necessary, vein grafts for arterial occlusion and primary amputation to the level of gangrenous tissue were performed. Conclusion: Treatment of severe digital ischemia can be a frustrating and unrewarding experience. In our 20-year experience we have found that a collaborative relationship between hand surgeon and hand therapist helps us to best serve our patients with Raynaud's syndrome. Information obtained in this organized approach aided our decisionmaking regarding medical and surgical management of this challenging group of patients.

Maxillary removal and reinsertion in pediatric patients.

To examine outcomes after the maxillary removal and reinsertion (MRR) approach for the treatment of anterior cranial base tumors in pediatric patients. Eligible patients were identified by medical record review. Consenting patients were studied via rhinoscopy, fiberoptic endoscopy, standard facial photographs, and cephalometric radiographs. A tertiary care otolaryngology clinic. Inclusion criteria were age younger than 16 years at time of initial procedure and a follow-up period of at least 6 months. Nine patients were eligible, and 5 enrolled. All were male patients (mean age, 13.8 years; age range, 11-15 years) treated for juvenile nasopharyngeal angiofibroma. History and examination were performed to evaluate occlusion, vision, facial growth, and tumor status. Cephalograms were used to calculate 3 standard cephalometric measurements: sella to A point, basion to A point, and condylion to A point. Cephalograms were examined for plate migration and bony resorption. No major long-term complications were identified in the patients after MRR. Cephalometric analysis revealed minor abnormalities in 2 children, but no plate migration or bony resorption was identified in the removed and reinserted maxillae. No abnormal development patterns were detected on physical examination or when cephalometric measurements were compared with age- and race-matched normative data. Although further study is warranted, MRR seems safe and effective for treatment of pediatric patients with anterior cranial base tumors.

Assessing a strategy of initial stand-alone extractional atherectomy followed by staged stent placement in degenerated saphenous vein graft lesions

To assess whether a staged strategy (initial stand alone transluminal extraction atherectomy and coumadin therapy followed by stenting six weeks later) could reduce ischemic complications in degenerated saphenous vein graft (SVG) interventions, we studied 72 patients undergoing percutaneous interventions of degenerated SVG. Patients were divided into two groups; 28 were treated with a staged strategy (group I) and 44 with similar lesion characteristics were treated with a definitive initial procedure with transluminal extraction atherectomy ± adjunctive balloon angioplasty and stenting (group II). Procedural success, major in-hospital complications (death, Q-wave myocardial infarction, and emergent coronary bypass surgery), and incidence of distal embolization were compared between the 2 groups. Procedural success was lower (92% vs 100%, p = 0.14) and major in-hospital complications were higher (0% vs 11%, p = 0.14) in group II. Distal embolization occurred in 11% of the patients in group I compared with 23% of the patients in group II (p = 0.19). At 6 week follow-up (group I), 9 patients (33%) had negative symptoms, 11 (41%) underwent stent implantation, 3 (11%) did not require any further therapy (without significant stenosis), and 4 (14%) had total occlusions. We therefore conclude that this staged strategy in degenerated SVG appears to reduce distal embolization but most importantly avoids major in-hospital complications, including any deaths either at the time of initial procedure or during the 6-week follow-up period.

Retropharyngeal abscess secondary to penetrating foreign bodies

A retrospective study was conducted on patients with upper aerodigestive tract foreign bodies requiring operative intervention over a 12-year period to aid in the recognition and management of foreign body associated complications. Oesophagoscopies were performed for the removal of foreign bodies in 37 patients, age one to 82 years with a male to female ratio of 1.2:1. Retropharyngeal abscesses accounted for eight of 11 foreign body-associated complications. Fish bones were the cause in six cases, chicken bone and a pen refill in one case each. An abscess was already present at the time of initial procedure in six cases and developed in two cases after successful removal of the foreign body. A high level of suspicion for a retropharyngeal abscess should be maintained in cases with perforation, and in patients with immunodeficiency.

Redo Gastric Restriction: A Higher Risk Procedure.

Twenty-one patients have undergone redo gastric restrictive procedures, three after gastric bypass, 18 after gastroplasty. Weight at the time of the redo procedure was 101 kg +/- 32.4 SD (222 lb +/- 71.2) (178% IBW +/- 33.8), down from 137 kg +/- 65.5) (217% ISW +/- 33.9) at the time of initial procedure. Sixteen of 21 (76%) initial procedures failed because of staple-line dehiscence, at least in part. Redo procedures were vertical banded gastroplasty (VBG) in ten, gastric bypass (GB) in ten, and silico ring banded gastroplasty in one. Early complications were three gastric leaks, one enterocutaneous fistula, one gastroplasty outlet obstruction, and one wound infection occurring in three of ten VBG and three of ten GB. All three leaks and one fistula were not seen on gastrograffin/barium swallow done 2-4 days after the redo procedure. Late complications were failure of seven redo procedures, one small bowel obstruction, and one recurrent enterocutaneous fistula, with two lost to follow-up. We conclude that redo gastric restriction procedures carry relatively high perioperative risks. Radiologic contrast studies done in the early postoperative period do not necessarily detect leaks, which are presumably due to gastric ischemia and subsequent infarction. Ischemia is thought to be due to devascularization from the initial procedure. Late failure is unfortunately common, possibly reflecting behaviors which lead to the initial staple line dehiscence and failure. Higher risk of perioperative complications and late failure must be considered prior to revisional surgery.