A randomized trial of endoscopic biliary sphincterotomy using pure-cut versus combined cut and coagulation waveforms

BACKGROUND & AIMS

Endoscopic biliary sphincterotomy has complication rates of 5%-12%. The output from the electrosurgical generator may influence the degree of coagulation and the rapidity of the incision, and thus rates of pancreatitis, hemorrhage, and perforation. Some modern generators incorporate feedback control to standardize output and automate the alternating cut and coagulation modes. Our aim was to compare 2 feedback-controlled generators, one with constant pure cutting-type output and the other with an alternating cut and coagulation mode.

METHODS

In this multicenter randomized study, 133 patients were assigned to the alternating cut/coag output and 134 patients were assigned to constant pure-cut output. Patients were stratified by their risk for pancreatitis.

RESULTS

The overall pancreatitis rate was 1.5%, including 3 patients in the cut/coag group and 1 patient in the pure-cut group (P>.05). There were 11 poorly controlled (zipper) incisions in the pure-cut group and none in the cut/coag group (P=.02). The incision was completed in all patients without stalling. Immediate hemorrhage occurred in 35 pure-cut patients and 8 cut/coag patients output (P=.002). There were no episodes of clinically significant bleeding, delayed bleeding, or perforation.

CONCLUSIONS

Biliary sphincterotomy using feedback-controlled generators results in dependable progression of incision with a low pancreatitis rate. Control of the incision is improved subjectively with the cut/coagulation output, but this did not translate into a difference in clinically significant complications.

Hemodilution and surgical hemostasis contribute significantly to transfusion requirements in patients undergoing coronary artery bypass

OBJECTIVE

We sought to determine the incidence of and risk factors for the development of low intraoperative hematocrit levels and of excessive postoperative bleeding in patients undergoing coronary artery bypass grafting, whether the risk factors are the same, and their effect on blood product transfusions.

METHODS

We performed a prospective cohort study of 613 adult patients who underwent coronary artery bypass grafting in 3 tertiary, university-affiliated hospitals during the period from October 1, 2000, to March 31, 2001.

RESULTS

Low intraoperative hematocrit levels (<19%) were found in 131 (24%) patients who had operations performed with extracorporeal circulation compared with in 3 (4%) patients with operations performed off pump. In multivariate analysis this was associated with older age, female sex, lower preoperative hemoglobin levels, lower body surface area, longer duration on bypass, and use of higher total volumes with more hydroxyethyl starch in the circuit. Low intraoperative hematocrit levels did not predict excessive postoperative hemorrhage (>1 L of mediastinal drainage in the first 12 hours). This occurred in 26% (n = 140) of patients undergoing on-pump operations and in 25% of patients undergoing off-pump operations and in multivariate analysis was associated with male sex, longer pump times, not receiving aprotinin, and operations performed by certain surgeons but not with total circuit or hydroxyethyl starch volume.

CONCLUSIONS

We observed that the risk factors for the development of a low intraoperative hematocrit level and excessive postoperative bleeding differed. Our results suggest that decreasing these outcomes in patients undergoing cardiac surgery requires a comprehensive approach, including limiting hemodilution, particularly in female subjects with lower preoperative hemoglobin levels, and careful attention to surgical hemostasis.

Minimally invasive transforaminal lumbar interbody fusion (TLIF): technical feasibility and initial results

Forty-nine patients underwent minimally invasive transforaminal lumbar interbody fusion (TLIF) from October 2001 to August 2002 (minimum 18-month follow-up). The diagnosis was degenerative disc disease with herniated nucleus pulposus (HNP) in 26, spondylolisthesis in 22, and a Chance-type seatbelt fracture in 1. The majority of cases (n = 45) were at L4-L5 or L5-S1. A paramedian, muscle-sparing approach was performed through a tubular retractor docked unilaterally on the facet joint. A total facetectomy was then conducted, exposing the disc space. Discectomy and endplate preparation were completed through the tube using customized surgical instruments. Structural support was achieved with allograft bone or interbody cages. Bone grafting was done with local autologous or allograft bone, augmented with recombinant human bone morphogenetic protein-2 in some cases. Bilateral percutaneous pedicle screw-rod placement was accomplished with the Sextant system. There were no conversions to open surgery. Operative time averaged 240 minutes. Estimated blood loss averaged 140 mL. Mean length of hospital stay was 1.9 days. All patients presenting with preoperative radiculopathy (n = 45) had resolution of symptoms postoperatively. Complications included two instances of screw malposition requiring screw repositioning and two cases of new radiculopathy postoperatively (one from graft dislodgement, the other from contralateral neuroforaminal stenosis). Narcotic use was discontinued 2-4 weeks postoperatively. Improvements in average Visual Analogue Pain Scale and Oswestry Disability Index (preoperative to last follow-up) scores were 7.2-2.1 and 46-14, respectively. At last follow-up, all patients had solid fusions by radiographic criteria. Results of this study indicate that minimally invasive TLIF is feasible and offers several potential advantages over traditional open techniques.

[Surgical treatment of aortic stenosis: which prosthesis for which patient?]

The long-term evolution following aortic valve replacement depends on the specific clinical context for each patient, but also on the type of prosthesis used. The increased hemorrhagic risk with mechanical prosthesis has to be weighed against the long-term risk of structural failure of bioprostheses. The patient's age will be a key determinant in the choice of the best suited prosthesis. Usually, bioprostheses are preferred after 70 years of age, while mechanical prostheses are chosen in patients under 65.

Robot-assisted Laparoscopic Aortobifemoral Bypass for Aortoiliac Occlusive Disease: Early Clinical Experience

BACKGROUND

Robotic technology may facilitate laparoscopic aortic reconstruction. We present our early clinical experience with laparoscopic aortobifemoral bypass, aided by two different robotic surgical systems.

METHODS

Between February 2002 and April 2004, we performed eight robot-assisted laparoscopic aorto-bifemoral bypasses for aortoiliac occlusive disease. All patients were male; median age was 55 years (range: 36-64). Dissection was performed laparoscopically and the robotic system was used to construct the aortic anastomosis.

RESULTS

A robot-assisted anastomosis was successfully performed in seven patients. Median operative time was 405 min (range: 260-589), with a median clamp-time of 111 min (range: 85-205). Median blood loss was 900 ml (range: 200-5800). Median anastomosis time was 74 min (range 40-110). In two patients conversion was necessary, one due to bleeding of an earlier clipped lumbar artery after completion of the anastomosis, the other because of difficulties with the laparoscopic exposure of the aorta. On post-operative day 3 one patient died unexpectedly as a result of a massive myocardial infarction. Median hospital stay was 7.5 days (range: 3-57).

CONCLUSION

Our initial experience with robotic assisted laparoscopic surgery (RALS) shows it is a feasible technique for aortoiliac bypass surgery. However, laparoscopic aortoiliac surgery demands considerable experience and operative times need to be reduced before this technique can be widely implemented.

The selection of pancreatic reconstruction techniques gives rise to higher incidences of morbidity: results of the 30th Japan Pancreatic Surgery Questionnaire Survey on pancreatoduodenectomy in Japan

BACKGROUND/PURPOSE

We aimed to determine the impact of the surgical strategy used for pancreatic reconstruction on morbidity after pancreatoduodenectomy (PD).

METHODS

A questionnaire was sent to all surgeon members of the Japan Pancreatic Surgery Club in December 2002.

RESULTS

We received 152 replies, and the data from all of them were used in the analysis. Thirty-six percent of the 152 responders performed PD and selected from among two or more pancreatic reconstruction techniques (PRTs). PRT selection was used no more frequently in the high- and medium-hospital-volume institutions than in low-hospital-volume institutions (25% or 37% vs 35%). The incidence of both "all arterial hemorrhage" and "delayed arterial hemorrhage" after PD in the institutions that used multiple PRTs was significantly higher than that in the institutions where only a single PRT was used (4.2% vs 2.2%, and 3.3% vs 1.5%, respectively; P < 0.05). In the high- and medium-hospital-volume institutions, the incidence of all arterial hemorrhage after PD in the multiple-PRT institutions was significantly higher than that in the single-PRT institutions (4.0% vs 1.9%; P < 0.05). Furthermore, in the low-hospital-volume institutions, the incidence of delayed arterial hemorrhage, 7 or more days after PD, was clearly higher in the multiple-PRT institutions than in the single-PRT institutions (4.1% vs 1.4%; P = 0.056). Therefore, the hospital-case volumes of PD were distributed as practice-case volumes according to the PRT by the selection of PRTs, and PRT selection gave rise to higher incidences of morbidity as a result of pancreatic leakage after PD.

CONCLUSIONS

The hospital-case-volume - better outcome relation for PD was attributable to expert pancreatic reconstruction skills that can be mastered only through frequent repetition.

A laboratory and clinical evaluation of single-use instruments for tonsil and adenoid surgery

OBJECTIVES

To compare the quality and consistency of single-use adenotonsillectomy instruments available in the UK with reusable instruments and examine their performance in a clinical setting.

DESIGN

A laboratory assessment of each reusable instrument created a detailed specification for the respective single-use equivalent. A surveillance system monitored the performance of a selected set of specified single-use instruments.

SETTING

Single-use instruments were withdrawn shortly after their introduction in 2001. Persisting concerns from the Spongiform Encephalopathy Advisory Committee led to an investigation into the feasibility of continuing to use such instruments.

MAIN OUTCOME MEASURES

The numbers of instruments from each set judged as unacceptable or as good as the original. The number and cause of instrument failure during clinical surveillance.

RESULTS

Between 40% and 93% of the instruments on each set were as good as the original and between 0% and 40% of the instruments were unacceptable from six sets of steel and one set of polymer instruments. 4151 procedures were monitored between 1 February 2003 and 31 March 2004 using a total of 41 376 instruments. Problems were reported with 335 (0.8%) instruments, 46% attributable to instrument design, 14% to poor design control and 13% to instruments escaping quality control systems. Following correction of the faults, between 1 January 2004 and 31 March 2004 the problem rate fell to 0.4%.

CONCLUSIONS

High quality single-use instruments for tonsil and adenoid surgery are available in the UK. Some companies offered inferior instruments not fit for their purpose. The procurement, introduction and subsequent clinical approval of single-use instruments requires a radically different approach to that currently applied to the purchase of reusable surgical equipment. Careful monitoring of their introduction is essential.

Fish oil before cardiac surgery: neutrophil activation is unaffected but myocardial damage is moderated

Could pre-operative dietary intervention with fish oil reduce neutrophil activation and myocardial damage associated with cardiopulmonary bypass (CPB)? Patients were randomised to receive either 8 g/day fish oil (n=22) or placebo (n=18) for 6 weeks. Neutrophil activation, apoptosis and cardiac damage were measured. Demographics and operative variables were similar. Fish oil diet decreased plasma VLDL from 0.69+/-0.34 to 0.51+/-0.24 mmol/l and triglycerides from 1.68+/-0.70 to 1.39+/-0.54 mmol/l. HDL cholesterol increased from 0.94+/-0.27 to 1.03+/-0.26 mmol/l demonstrating significant treatment effects (P=0.007, 0.02 and 0.0003, respectively) as well as compliance with treatment. There were no significant differences in ex vivo N-formyl-methionyl-leucyl-phenylalanine-stimulated neutrophil superoxide anion generation or myeloperoxidase release at recruitment, pre-operatively and at end-CPB. Apoptosis at end-CPB was equally reduced in both groups from 23+/-9% to 13+/-4% in the fish oil group (P<0.001) and 35+/-14% to 15+/-3% in the placebo group (P=0.001). At end-CPB overall troponin I levels averaged 0.91+/-0.60 ng/ml which clearly exceeded diagnostic levels (0.15 ng/ml). At 24h troponin I fell significantly in the fish oil group to 46+/-23% of end-CPB levels (P=0.0002) whereas it peaked in the placebo group to 107+/-72% (P=0.098 vs. end-CPB); this difference was significant: P=0.013. At 48 h the placebo-treated patients had higher troponins but not significantly so (P=0.059). Area-under-the-curve analysis did not conclusively support this (P=0.068). We conclude that fish oil did not significantly decrease post-CPB neutrophil activation (as detected ex vivo) but may moderate post-operative myocardial damage.

Laparoscopic appendectomy: a series of cases utilizing laparosonic coagulating shears as compared to endo-GIA and endoshears

OBJECTIVE

To report a series of laparoscopic appendectomies utilizing laparosonic coagulating shears (LCS) (harmonic scalpel).

STUDY DESIGN

We conducted a retrospective chart underwent laparoscopic appendectomy at Walter Reed Army Medical Center between January 1, 1996, and December 31, 2001. Procedures were included if only 1 instrument was utilized for transection of the appendix: endoshears, endo-GIA (Tyco U.S. Surgical, Norwalk, Connecticut) or LCS. Procedures on ruptured appendixes and emergency procedures were excluded. Outcome variables of interest included operative time, estimated blood loss, length of hospital stay and complications.

RESULTS

Mean estimated blood loss, mean operative times and hospital stay were consistent with those of other techniques of laparoscopic appendectomy. LCS was used more frequently for appendectomy performed at the time of another procedure than were endo-GIA and endoshears. There were no complications in the harmonic scalpel laparoscopic appendectomy series.

CONCLUSION

This series demonstrates that laparoscopic appendectomy with LCS has low morbidity and is as efficacious as other methods of laparoscopic appendectomy.

Laparoscopic liver resection of hepatocellular carcinoma

BACKGROUND

We have continued to develop laparoscopic hepatectomy as a means of surgical therapy for hepatocellular carcinoma (HCC).

METHODS

We evaluated the degree of invasiveness and analyzed the outcomes of laparoscopic hepatectomy compared with open hepatectomy for HCC.

RESULTS

There were notable differences with respect to blood loss and operating time compared with open hepatectomy cases. Patients started walking and eating significantly earlier in the laparoscopic hepatectomy group, and these more rapid recoveries allowed shorter hospitalizations. On the Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system, there was no difference in preoperative risk. However, a significant difference was seen in the surgical stress and comprehensive risk scores between the open hepatectomy and laparoscopic hepatectomy groups. Concerning the survival rate and disease-free survival rate, there were no significant differences between procedures.

CONCLUSIONS

Laparoscopic hepatectomy avoids some of the disadvantages of open hepatectomy and is beneficial for patient quality of life (QOL) as a minimally invasive procedure if the operative indications are appropriately based on preoperative liver function and the location and size of HCC.

Complications associated with surgical management of ranulas

PURPOSE

We present the intraoperative and postoperative complications associated with 606 procedures for ranulas in a series of 571 patients.

PATIENTS AND METHODS

Clinical records of 606 procedures in 571 patients with ranulas operated on in the Hospital of Stomatology, Wuhan University, China between 1962 and 2002 were retrospectively reviewed. The methods of surgery and intraoperative and postoperative complications were documented and analyzed.

RESULTS

The most common complications were recurrence of the lesion (5.78%) and sensory deficit of the tongue (4.89%), followed by damage of Whartons duct (1.82%). Postoperative hematoma, infection, or dehiscence of the wound were seldom seen. Temporary numbness of the tongue resolved within 2 to 7 months postoperatively. Recurrences were often seen after marsupialization and excision of the ranula, with few recurrences after excision of the ranula and sublingual gland or excision of the sublingual gland alone.

CONCLUSION

Complications associated with ranula surgery are minor and self-limiting. Transoral excision of the sublingual gland has the least possibility of ranula recurrence.

Anterior Versus Posterior Treatment of Stable Thoracolumbar Burst Fractures Without Neurologic Deficit

OBJECTIVE

A prospective randomized study was conducted to determine whether there exist any differences in radiographic, clinical, or functional outcomes when individuals with stable burst fractures of the thoracolumbar junction without neurologic deficit are treated with either a posterior fusion with instrumentation or anterior reconstruction, fusion, and instrumentation. There exists relatively little literature evaluating the outcomes of individuals treated with anterior surgery, and no prospective randomized studies exist comparing the two treatment approaches.

METHODS

From May 1995 to March 2001, a consecutive series of subjects with acute isolated burst fractures of the thoracolumbar junction (T10-L2) without neurologic deficit were randomized to receive either an anterior fusion with instrumentation or a posterior fusion with instrumentation. Radiographs including computed tomography (CT) were obtained. Radiographs were repeated at 2, 4, 6, 12, and 24 months. The CT scan was also repeated at 24 months. Hospital stay, cost, operating time, blood loss, complications, and patient-related functional outcomes were measured.

RESULTS

Of 43 enrolled, 38 completed a minimum of 2-year follow-up (average: 43 months; range: 24-108 months). Eighteen received a posterior spine fusion and 20 an anterior approach. Hospital stay and operating time were similar. Blood loss was higher in the group treated anteriorly; however, the incidence of transfusion was the same. There were 17 "complications" including instrumentation removal for pain in 18 patients treated posteriorly, but only 3 minor complications in 3 patients treated anteriorly. Patient-related functional outcomes were similar for the two groups.

CONCLUSIONS

Although patient outcomes are similar, anterior fusion and instrumentation for thoracolumbar burst fractures may present fewer complications or additional surgeries.

Single-Surgeon Simultaneous Versus Staged Anterior and Posterior Spinal Reconstruction

BACKGROUND

Complex three-column disease of the thoracic or thoracolumbar spine often requires anterior and posterior surgical approaches for complete decompression and reconstruction. Although this has traditionally been accomplished with staged procedures, recent reports describe treatment with simultaneous anterior-posterior procedures, typically utilizing two spinal surgical teams. This study compares the surgical treatment of 14 patients, all with three-column disease of the thoracic or thoracolumbar spine, treated at a single institution.

METHODS

Half were treated by the author with single-surgeon simultaneous anterior-posterior surgical reconstruction, whereas half were treated by another surgeon with staged anterior and posterior approaches. The indications, operative details, hospital course, neurologic outcome, complications, and degree of deformity correction were compared through prospective and retrospective analysis.

CONCLUSIONS

Single-surgeon simultaneous anterior-posterior reconstruction represents a safe and practical approach to the treatment of three-column complex pathology of the thoracic or thoracolumbar spine and may allow better correction of deformity than staged procedures.

[Assessment of transfusion requirements: a way to in improve perioperative management of blood products?]

Autogenic blood transfusion is indispensable in emergency surgery situations involving severe blood loss. It may also be required in some non-emergency surgical and obstetrical situations. The use of blood-sparing techniques as an alternative to autogenic blood transfusions blood loss can be especially beneficial in tropical settings where the risk of viral transmission is high. The combined use of blood-sparing and autogenic transfusion techniques requires preoperative assessment of transfusion requirements. The expected amount of preoperative blood loss must be determined and compared with the acceptable amount of blood loss for the patient in function of transfusion threshold. Various techniques to reduce the need for autogenic blood transfusion can be used depending on locally available resources. Blood-sparing techniques include treatment to increase the patient's baseline hemoglobin rates, use of cell saving systems for autologous blood transfusion, and/or perioperative transfusion of recuperated blood. In this article these techniques are illustrated in two practical clinical cases.

Safety of outpatient tonsillectomy in children: a review of 6 years in a tertiary hospital experience

OBJECTIVE

We present our experience with outpatient tonsillectomy in children and critically review safety to support the outpatient policy.

STUDY DESIGN AND SETTING

We conducted a retrospective chart review from January 1995 through December 2000 in the pediatric otolaryngology unit of a tertiary care university hospital.

RESULTS

One thousand two hundred forty-three patients were accepted in the outpatient program with permissive criteria. Postoperative observation time ranged from 3 to 5 hours (median, 4.5 hours). The overall rate of complications was 9.3% (n = 116). Primary and secondary bleeding rates were 6.27% (n = 78) and 0.48% (n = 6), respectively. Thirty-six children (2.9%) had major bleeding; 2 of them were not identified in day-hospital (0.16%). Discharge was delayed in 103 patients (8.3%), and 13 patients showed complications after discharge (about 1% readmission rate).

CONCLUSION

Our program outcomes support safety. Outpatient surgery is meant to provide comfort to the patient and efficiency to the health care system, without impairing safety; in our experience, most tonsillectomies in children comply with these objectives.

SIGNIFICANCE

Outpatient tonsillectomy in children may be safe even with permissive criteria, when an appropriate setting is available.

[Preoperative adverse events during stereotactic microelectrode-guided deep brain surgery in Parkinson's disease]

OBJECTIVES

To evaluate the prevalence of adverse events and complications during surgery using deep brain electrodes, mainly in the treatment of Parkinsonism. To describe the adjustment of propofol to meet the needs of neurophysiological monitoring.

PATIENTS AND METHODS

A prospective study of patients undergoing stereotactic microelectrode-guided deep brain surgery (stereotactic pallidotomy, implantation of electrodes in the thalamic or subthalamic neurons of the globus pallidus). After placement of a stereotactic frame and completion of a computed tomography scan of the head, the patients were transferred to the operating room. Monitoring included electrocardiography, pulse oximetry, arterial pressure (invasive), endtidal carbon dioxide pressure, and diuresis. Anesthesia was maintained by intermittent infusion of propofol. Variables recorded were age, sex, disease and time elapsed since diagnosis, surgical complications and their treatment, total dose of propofol, duration of surgery, and place of transfer for recovery.

RESULTS

One hundred twenty-eight patients (50 women, 78 men) with a mean (+/- SD) age of 59.6 +/- 10.2 years underwent the procedure from 1996 through 2003. The mean time elapsed since diagnosis of the disease was 14 +/- 6.2 years. The propofol dose was 890.6 +/- 571.4 mg and duration of surgery was 8.3 +/- 2.4 hours. Adverse events were observed for 101 patients (78.9%). The most common complications involved hemodynamics: arterial hypertension (59.4%), bradycardia (18.0%), arterial hypotension (7.9%), and tachycardia (6.2%). Other more serious complications were pneumocephalus with clinical repercussions (3 cases), globus pallidus hematoma (2), air embolism (2), epileptic seizure (3), anisocoria (1), and dyspnea and/or airway obstruction (7).

CONCLUSIONS

Deep brain stimulation requires surgery of long duration. Because of frequent episodes of arterial hypertension, which increases the risk of brain hemorrhage, and other less common but potentially dangerous complications, careful clinical monitoring is necessary during the procedure. The intermittent use of propofol does not interfere with neurophysiological monitoring.

Surgical reinforcement of support for the vagina in pelvic organ prolapse: concurrent iliococcygeus fascia colpopexy (Inmon technique)

To reinforce the support of the vagina, concurrent use of iliococcygeus fascia colpopexy with the McCall culdeplasty was scheduled for primary uterine prolapse. Forty-five women with primary uterine prolapse without stress urinary incontinence were treated by McCall culdeplasty alone or McCall culdeplasty plus iliococcygeus fascia colpopexy for suspension of the upper portion of the vagina. Recurrence of vaginal support defects were carefully followed for 15-50 months. Additional iliococcygeus fascia colpopexy did not change with the axis of the vagina obtained by McCall culdeplasty, although it prolonged total operation time by 32 min and increased blood loss by 94 ml. Two cases (8.3%) had postoperative vaginal defects in the group undergoing combined procedures and seven recurrent cases (33.3%) were observed in the group undergoing McCall culdeplasty alone. The durability of the combined procedures was superior to that of the modified McCall culdeplasty alone by Kaplan-Meier analysis. These results suggest that iliococcygeus fascia colpopexy is reasonably safe and strengthens not only the attachment of the upper part of the vagina but also that of the anterolateral vaginal wall.

[Postoperative bleeding after tooth extractions in patients controlled with warfarin--a clinico-statistical study on the factors influencing postoperative bleeding]

There are many reports about tooth extractions of patients taking warfarin, however PT-INR level is used to examine the postoperative bleeding in patients. To investigate other factors, postoperative bleeding, age, gender, PT-INR level, combined use of anti-platelet drugs, conditions of extracted tooth, a number of tooth extractions at a treatment, methods of management for warfarin therapy, degree of the alveolar bone loss and size of radiolucency of apical region were examined in this study. To apply Mann-Whitney U-test and chi2-test, ninety-three patients (38 male and 55 female) who took warfarin and visited our clinic for tooth extractions from April 1994 to November 2002 were classified into 2 groups: One group showed hemostasis by the next day (77 patients), the other showed the continuous bleeding after the next day (16 patients). These analyses indicated that PT-INR level, a number of tooth extractions at a treatment, methods of management for warfarin therapy, and size of radiolucency of apical region influenced postoperative bleeding. In addition, stepwise logistic regression analysis was applied to all of the factors, obtained from 77 patients out of 93 patients. This data showed that PT-INR level, a number of tooth extractions at a treatment and methods of management for warfarin therapy influenced postoperative bleeding. These results suggest that before the tooth extractions not only PT-INR level but methods of management for warfarin therapy and size of wound could be important to control the postoperative bleeding in warfarin taking patients.

Gait adaptation in ACL deficient patients before and after anterior cruciate ligament reconstruction surgery

The objective of this study is to determine how kinematical parameters and electromyography data of selected muscles may change as a result of anterior cruciate ligament (ACL) deficiency and following ACL reconstruction. The study was conducted on 25 anterior cruciate ligament deficient subjects prior to and 6 weeks, 4 months, 8 months and 12 months following ACL reconstructive surgery using the bone-patellar tendon-bone technique. Gait analysis was performed by applying the zebris three-dimensional ultrasound-based system with surface electromyograph (zebris). Kinematic data were recorded for the lower limb. The muscles surveyed include vastus lateralis and medialis, biceps femoris and adductor longus. The results obtained from the injured subjects were compared with those of 51 individuals without any ACL damage whatsoever. Acute ACL deficient patients exhibited a quadriceps avoidance pattern prior to and 6 weeks following surgery. No quadriceps avoidance phenomenon develops in chronic ACL deficient patients. In operated individuals, tempo-spatial parameters and the knee angle regained a normal pattern for the ACL-deficient limb during gait as early as 4 months following surgery. However, the relative ACL movement parameter, which describes the tibial translation into the direction of ACL, and the EMG traces show no significant statistical difference compared with the same values of the healthy control group just 8 months following surgery. The analysis of spatial-temporal parameters and EMG traces show that the development of a quadriceps avoidance pattern is less common than previously reported. These data suggest that anterior cruciate ligament deficiency and reconstruction produce considerable changes in the lower extremity gait pattern. The results suggest that gait parameters tend to shift towards a normal value pattern; and the re-establishment of pre-injury gait patterns-including the normal biphase of muscles-takes at least 8 months to occur.

Comparison of conventional versus minimally invasive extraperitoneal approach for anterior lumbar interbody fusion

The purpose of the study was to compare conventional versus minimally invasive extraperitoneal approach for anterior lumbar interbody fusion (ALIF). Fifty-six consecutive patients with spondylolisthesis, lumbar instability, or failed back syndrome were treated with ALIF between 1991 and 2001. The patients were retrospectively evaluated and divided in two groups: Group 1, consisting 33 patients, was treated with ALIF using the conventional retroperitoneal approach, and Group 2, consisting of 23 patients, was operated with the minimally invasive muscle-splitting approach for ALIF. The groups were comparable as regards age, indication of fusion, and diagnosis. All patients in both groups had fusion with autologous iliac crest grafts and posterior instrumentation with posterolateral fusion in the same sitting. Clinical evaluation was done by two questionnaires: the North American Spine Society (NASS) Lumbar Spine Outcome Assessment Instrument and the Nottingham Health Profile (NHP). Fusion rate was evaluated radiologically. Mean clinical follow-up was 5.5 years. There was no statistical difference in the occurrence of complications with both approaches nor with the fusion rates of 92% in group 1 and 84% in group 2 respectively. The minimally invasive extraperitoneal approach for ALIF was associated with significantly less intraoperative blood loss, operation time, and length of the skin incision. In addition, this approach showed significant improvement in postoperative back pain in comparison to the conventional approach for ALIF.

Consent for tonsillectomy

Rulings in recent negligence cases reveal a shift towards what the 'reasonable patient' would expect in deciding the risks doctors must disclose to patients. This survey aimed to investigate whether the 'reasonable patient' and 'responsible body of medical opinion' agree about which risks should be discussed regarding tonsillectomy. Using questionnaires, surgeons were asked which of the 10 complications they routinely discussed and patients were asked how seriously they regarded these complications. The results were compared with the Test of Proportions. Most surgeons routinely mentioned otalgia, odynophagia, throat infection and re-operation. Most patients regarded potentially fatal bleeding, pneumonia and blood transfusion as very serious but only the minority of surgeons mentioned these (P < 0.001). When obtaining consent for tonsillectomy, surgeons do not routinely mention all the risks that the 'reasonable patient' would expect. The 'reasonable patient' would expect that re-operation, transfusion, pneumonia and fatal blood loss are discussed.

Acute phase response in patients undergoing lumbar spinal surgery: modulation by perioperative treatment with naproxen and famotidine

In orthopaedic surgery, perioperative administration of non-steroidal anti-inflammatory drugs has been shown to reduce postoperative pain and analgesic consumption. In addition, preoperative administration of ibuprofen has proved to reduce interleukin-6 (IL-6) release, while that of ranitidine reduced postoperative IL-6-induced C-reactive protein synthesis in patients undergoing abdominal surgery. However, it has not been established whether the preoperative administration of both types of drugs may reduced the postoperative inflammatory reaction after instrumented spinal surgery. Accordingly, our objective was to investigate the effects of preoperative treatment with naproxen plus famotidine on the postoperative systemic inflammatory reaction in patients undergoing instrumented lumbar spinal surgery. Forty consecutive patients scheduled for elective instrumented spinal fusion were alternately assigned to receive either naproxen (500 mg/day, p.o.) plus famotidine (40 mg/day, p.o.) for 7 days before operation, or no adjuvant treatment. Haematological parameters, acute phase proteins, complement fractions, immunoglobulins and cytokines were determined 7 days and immediately before surgery, and on days 0, 1, 2 and 7 after surgery. Haematological parameters, clinical data, duration of surgery, blood loss, perioperative blood transfusion and postoperative complications were similar in the two groups, although pretreated patients showed lower increases in body temperature and required less analgesic medication. Compared with preoperative levels, IL-6 levels were significantly increased postoperatively in all patients with no differences between groups. C-reactive protein, alpha(1)-acid-glycoprotein and haptoglobin levels were also significantly increased postoperatively in all patients; however, they were significantly lower in pretreated patients. In conclusion, perioperative treatment with naproxen plus famotidine was well tolerated and reduced the acute phase response after instrumented spinal surgery. However, further research is needed to determine the best dose and timing of preoperative treatment administration, and to correlate these changes with long-term clinical results.

Esophageal perforation as a complication of EndoCinch endoluminal gastroplication

Endoscopic gastroplasty is being promoted as a new minimally invasive procedure for the treatment of gastroesophageal reflux disease. In the case presented here, however, we encountered abdominal perforation as a severe complication of this procedure. Because immediate action was taken when the symptoms developed, and by maintaining close collaboration with the surgeons, it was possible to keep the treatment minimally invasive: the leakage was detected endoscopically and the defect was closed laparoscopically and covered by a fundoplication. This experience emphasises the importance of appropriate management of complications as part of the evaluation of new endoscopic methods.