Appropriateness of Invasive Cardiovascular Interventions in German Hospitals (2000 - 2001): An Evaluation Using the RAND Appropriateness Criteria

OBJECTIVE

Germany has the highest per capita rate of percutaneous transluminal coronary angioplasties (PTCAs) in Europe and the third highest per capita rate of heart surgeries requiring a heart-lung machine. The goal of this study was to evaluate the appropriateness of PTCA, coronary artery bypass graft (CABG), and carotid endarterectomy (CEA) in German hospitals using RAND appropriateness criteria.

METHODS

A retrospective study in 121 randomly selected German hospitals (52 % of all hospitals contacted) was performed from December 2000 to August 2001. A total of 361 patients were enrolled providing information on the appropriateness of 128 PTCAs, 92 CABGs, and 141 CEAs.

RESULTS

Inappropriateness rates were 2 % (95 % CI 0 - 5 %), 4 % (95 % CI 1 - 9 %), and 3 % (95 % CI 1 - 7 %) for PTCA, CABG, and CEA, respectively. The overall rate of uncertain procedures was 42 % (95 % CI 36 - 47 %). Only 38 % (95 % CI 32 - 45 %) of patients who received a coronary intervention had had a pre-interventional stress test.

CONCLUSIONS

The study yielded little overt overuse in the performance of PTCAs, CABGs, and CEAs, but potentially large underuse of stress tests. Despite a high per capita rate of invasive cardiovascular interventions in Germany, the rate of inappropriate procedures was not larger than in other countries.

The benefits of a dedicated minimally invasive surgery program to academic general surgery practice

In 2001, a dedicated minimally invasive surgery (MIS) program was established at a large university hospital. Changes included improvement and standardization of equipment and instruments, patient care protocols, standardized orders, and staff education. The aim of this study was to evaluate the impact of this program on an academic surgery practice. From January 1999 through October 2003, hospital and departmental databases were reviewed for all records pertaining to general surgery cases. Data trends were analyzed by regression analysis and are expressed as mean +/- SEM. In 1999, 15.0 +/- 0.1% of all general surgery cases were MIS cases compared with 30.2 +/- 0.1% in 2003 (P < 0.0001). During this period, the number of patients requiring conversion from a laparoscopic to an open approach decreased from 14.4% to 4.0% (P = 0.0007). In 1999, 30% of appendectomies were laparoscopic, compared with 92% in 2003 (P < 0.0001). This increase in the rate of laparoscopic appendectomy resulted in a decrease in average length of hospital stay for all patients with acute appendicitis, from 5.5 +/- 1.0 days in 1999 to 2.7 +/- 0.2 days in 2003 (P < 0.0001), and a decrease in total hospital cost per case, from 6569 +/- 400 US dollars in 1999 to 4819 +/- 175 US dollars in 2002 (P < 0.001). Total operating room time per case for cholecystectomy decreased from 131 +/- 3.7 to 108 +/- 3.2 minutes (P < 0.0001), and actual surgery time decreased from 95 +/- 4.1 to 74 +/- 4.0 minutes (P = 0.0006). Implementation of a dedicated MIS program resulted in a significant increase in the number of MIS cases and percentage of general surgery cases performed by MIS. This increase in the utilization of MIS resulted in reduced length of stay and cost and has been accompanied by improvements in operating room efficiency. Changes in practice associated with development of an MIS program have had measurable institutional benefits.

New OR streamlines surgeries, increases caseload

The number of surgeries using minimally invasive equipment has been growing rapidly at Children's Hospital of Pittsburgh, as both referring physicians and parents seek out surgeons using techniques that allow for quicker recovery and less scarring. In 2000, there were 276 minimally invasive surgeries performed at CHP. By 2003, the number had grown to 514 and so far in 2004 almost 700 such cases have been done.

Laparoscopic nephron-sparing surgery for two or more ipsilateral renal tumors

OBJECTIVES

To review our experience with laparoscopic nephron-sparing surgery in the management of two or more synchronous, ipsilateral renal masses. Minimally invasive nephron-sparing procedures are increasingly used for the treatment of select patients with a single, small renal tumor.

METHODS

Since 1998, we have performed laparoscopic nephron-sparing surgery in 288 consecutive patients, including laparoscopic partial nephrectomy (n = 200) and renal cryotherapy (n = 88). Of these, 13 patients (4.5%) were treated for synchronous ipsilateral renal masses.

RESULTS

A total of 27 renal tumors were treated in 13 patients. The patients were divided into four groups on the basis of the treatment. Group 1 (n = 3) underwent en-bloc laparoscopic partial nephrectomy encompassing both tumors; group 2 (n = 2) underwent individual laparoscopic partial nephrectomy of discrete masses during the same procedure; group 3 (n = 2) had one mass treated with partial nephrectomy and the other mass treated with cryotherapy; and group 4 (n = 6) had all tumors treated with cryotherapy. All cases were completed successfully without conversion to open surgery or laparoscopic nephrectomy. The mean overall operative time was 4.3 hours, and the mean blood loss was 169 mL. No intraoperative complications occurred. Three patients had postoperative complications, none requiring re-exploration. One patient in group 4 developed de novo tumors in the treated kidney, located distant from the cryoablated sites.

CONCLUSIONS

Laparoscopic partial nephrectomy is an emerging, efficacious laparoscopic treatment option for select patients. Laparoscopic cryotherapy is a useful alternative or adjunct to partial nephrectomy. The judicious combination of these complementary techniques further extends the scope of minimally invasive nephron-sparing surgery.

Evaluation of quality of life after laparoscopic surgery: evidence-based guidelines of the European Association for Endoscopic Surgery

BACKGROUND

Measuring health-related quality of life (QoL) after surgery is essential for decision making by patients, surgeons, and payers. The aim of this consensus conference was twofold. First, it was to determine for which diseases endoscopic surgery results in better postoperative QoL than open surgery. Second, it was to recommend QoL instruments for clinical research.

METHODS

An expert panel selected 12 conditions in which QoL and endoscopic surgery are important. For each condition, studies comparing endoscopic and open surgery in terms of QoL were identified. The expert panel reached consensus on the relative benefits of endoscopic surgery and recommended generic and disease-specific QoL instruments for use in clinical research.

RESULTS

Randomized trials indicate that QoL improves earlier after endoscopic than open surgery for gastroesophageal reflux disease (GERD), cholecystolithiasis, colorectal cancer, inguinal hernia, obesity (gastric bypass), and uterine disorders that require hysterectomy. For spleen, prostate, malignant kidney, benign colorectal, and benign non-GERD esophageal diseases, evidence from nonrandomized trials supports the use of laparoscopic surgery. However, many studies failed to collect long-term results, used nonvalidated questionnaires, or measured QoL components only incompletely. The following QoL instruments can be recommended: for benign esophageal and gallbladder disease, the GIQLI or the QOLRAD together with SF-36 or the PGWB; for obesity surgery, the IWQOL-Lite with the SF-36; for colorectal cancer, the FACT-C or the EORTC QLQ-C30/CR38; for inguinal and renal surgery, the VAS for pain with the SF-36 (or the EORTC QLQ-C30 in case of malignancy); and after hysterectomy, the SF-36 together with an evaluation of urinary and sexual function.

CONCLUSIONS

Laparoscopic surgery provides better postoperative QoL in many clinical situations. Researchers would improve the quality of future studies by using validated QoL instruments such as those recommended here.

The IDET procedure for chronic discogenic low back pain

STUDY DESIGN

Retrospective study with independent evaluation of patient outcomes approximately 1 year post-intradiscal electrothermal therapy (IDET). OBJECTIVE.: To assess functional status, symptoms, and subsequent treatments of patients treated with IDET.

SUMMARY OF BACKGROUND DATA

IDET was introduced as a procedure for discogenic pain. Several studies reported improvement in >70% of patients.

METHODS

Seventeen physicians referred 60 patients. Each patient had a positive discogram and had been treated with IDET. Patients were contacted approximately 1 year post-IDET, answered a telephone interview, and completed a self-administered questionnaire. Overall patient satisfaction, pain, functional and work status, analgesic usage, and subsequent treatments were noted. Kaplan-Meier survival curve was generated to predict the percentage that would undergo lumbar surgery after IDET.

RESULTS

Average age was 40 years (range 25-64 years) with 66% males and 34% females. Of the 44 patients who responded, 6 patients had a lumbar surgery within 1 year. Their outcomes were excluded from descriptive analysis; 97% continued to have back pain, 11 (29%) reported more pain post versus pre-IDET, 15 (39%) had less pain, and 11 (29%) reported no change; 11 (29%) reported using more pain medication post-IDET, 10 (26%) used the same, 12 (32%) used less, and 5 (13%) used none; 19 (50%) were dissatisfied with IDET, 14 (37%) were satisfied, and 5 (13%) were undecided; 20 (53%) would have the procedure again, 12 (31%) would not, and 6 (16%) were unsure. Most patients wore a brace >6 hours/day after surgery (duration 1-15 months). Sixteen (42%) were employed full-time pre-IDET and 11 (29%) were employed full-time post-IDET.

CONCLUSION

At 1-year post-IDET, half of patients were dissatisfied with their outcome. The percentage of patients on disability remained constant. The estimated proportion of patients undergoing fusion was predicted to be 15% at 1 year and 30% at 2 years.

Minimally invasive surgical practice: a survey of general surgeons in Ontario

INTRODUCTION

With the rapidly evolving techniques for minimally invasive surgery (MIS), general surgeons are challenged to incorporate advanced procedures into their practices. We therefore carried out a study to assess the state of MIS practice in Ontario.

METHODS

A questionnaire was mailed to 390 general surgeons in Ontario. It addressed the surgeon's practice demographics, performance of both basic and advanced MIS procedures, the factors influencing this practice and the means of obtaining MIS training.

RESULTS

Of the 390 general surgeons surveyed, 309 (79%) responded. Thirty-six of these were retired and were excluded from the analysis, leaving 273 available for study. The average age in the study group was 49.7 years; 247 (90%) were men. Of 272 who responded to the question, 116 (43%) had subspecialty training. The average surgeon's operating room (OR) time was 1.5 d/wk and the average waiting time for elective procedures was 4 weeks. We found that 257 (94%) respondents performed basic laparoscopic procedures, and 164 (60%) performed appendectomy; 135 (49%) performed at least 1 advanced laparoscopic procedure in their practice, although only 30 (22%) of these performed inguinal hernia repair. Using a Likert scale, we found that the most important factors influencing the incorporation of advanced laparoscopic procedures into surgical practice were a lack of OR time (median 4), lack of OR financial resources (median 4) and lack of training opportunities (median 4). Of surgeons responding to questions, 161 (64%) of 251 felt that the present medical environment did not allow them to meet standard-of-care requirements; they felt that it was the responsibility of academic surgical departments (214 [80%] of 268), the Canadian Association of General Surgeons (177 [68%] of 262) and the Ontario Association of General Surgeons (141 [53%] of 264) to provide continuing medical education courses for MIS training.

CONCLUSION

The ability of practising general surgeons to incorporate advanced MIS procedures into their surgical practice remains a complex issue.

Laparoscopic pancreatic surgery: current indications and surgical results

BACKGROUND

Although minimally invasive surgery has achieved worldwide acceptance in various fields, laparoscopic surgery for pancreatic diseases has been reported only rarely. The purpose of this study was to evaluate the outcomes and feasibility of laparoscopic pancreatic surgery.

METHODS

Fifteen patients, comprising eight men and seven women with an average age of 54 years, underwent laparoscopic pancreatic surgery. Distal pancreatectomy was indicated for solid tumors ( n = 4), cystic lesions ( n = 3), and chronic pancreatitis ( n = 2). Cystogastrostomy was performed for pseudocysts ( n = 4) and enucleation for insulinomas ( n = 2). The lesions varied in size from 1 to 9 cm (2.9 +/- 2.4 cm) and were located in the pancreatic head ( n = 2), body ( n = 3), or tail ( n = 10). For distal pancreatectomy, the splenic artery was divided and the parenchyma was transected with a linear stapler. Laparoscopic ultrasonography was used to determine the distance between the tumor and the main pancreatic duct for enucleation as well as to localize the lesion for distal pancreatectomy. Cystogastrostomy, 4.5 cm in length, was also performed with the linear stapler through the window of the lesser omentum.

RESULTS

Mean operation time was 249 +/- 70 min (293 +/- 58 min in distal pancreatectomy, 185 +/- 14 min in enucleation, 204 +/- 50 min in cystogastrostomy), and mean blood loss was 138 +/- 184 g (213 +/- 227 g, 75 +/- 35 g, 38 +/- 48 g, respectively). Two distal pancreatectomies (13%) were converted to open surgery due to severe peripancreatic inflammation. There was no related mortality, but there were two cases (15%) of pancreatic fistula, one in a distal pancreatectomy case and the other in an enucleation case, and both were treated conservatively.

CONCLUSIONS

Laparoscopic pancreatic surgery is safe and feasible for patients with benign tumors and cystic lesions.

Current status of laparoscopic gastrectomy for cancer in Japan

Because of the increased incidence of early gastric cancer in Japan, minimally invasive laparoscopic approaches to gastric malignancies have been under development since 1991. Laparoscopic local resection of the stomach, i.e., laparoscopic wedge resection (LWR) and intragastric mucosal resection (IGMR), is used to treat mucosal cancer without lymph node metastasis. Laparoscopy-assisted distal gastrectomy (LADG) is used to treat early gastric cancer with risk factors for regional lymph node metastasis. A survey conducted by the Japan Society for Endoscopic Surgery showed that 1428 LWRs, 260 IGMRs, and 2600 LADGs were performed between 1991 and 2001 in departments of endoscopic surgery in Japan. Laparoscopic gastrectomy for gastric cancer is still under development in Japan. According to short-term results reported by a small group of surgeons, laparoscopic approaches to gastric cancer provide for minimal invasion, early recovery, and decreased morbidity and mortality. If the advantages can be confirmed in one or more multicenter randomized control studies of the long-term outcome of patients undergoing laparoscopic gastrectomy for gastric cancer, the procedure should come into wide acceptance and use.

Management of symptomatic benign prostatic hyperplasia in southern Italy: a retrospective analysis of the Sicilian-Calabrian Society of Urology (SSCU) of 32,000 patients

INTRODUCTION

The availability of new pharmacological and surgical options is responsible for important changes in the management of symptomatic benign prostate hyperplasia (BPH). The Sicilian-Calabrian Society of Urology performed a retrospective survey to assess the management of BPH in southern Italy in 1997 and 1998.

PATIENTS AND METHODS

A 3-page questionnaire was sent to the 36 urological units of these two regions. The real number of patients treated was required. The numbers were checked with data obtained from the Health Regional Offices.

RESULTS

Twenty-six urological units (72.3%) replied. Almost all patients underwent urinalysis, determination of serum prostate-specific antigen and creatinine levels, and renal and postvoid vesical echography. Uroflowmetry was performed in 69% and transrectal ultrasound in 56% of the patients. International Prostate Symptom Score or other symptom scores were used in 36% of the cases. Out of 31,558 patients with symptomatic BPH, 5,636 were surgically treated. Admission was due to acute urinary retention in 1,324 cases (23.5%). Transurethral resection of the prostate was the commonest procedure, accounting for 59.5% of the interventions. Open prostatectomy was performed in 1,804 patients (32%). Minimally invasive therapies accounted for less than 9% of the treatments.

CONCLUSIONS

The present survey provides a picture of the current surgical practice in BPH in southern Italy in the late 1990s. Symptom scores are not routinely adopted. The low rate of transurethral prostate resections is in keeping with the worldwide decline. On the contrary, a high rate of open prostatectomies has been detected.

Predictors of prolonged ICU stay after on-pump versus off-pump coronary artery bypass grafting

OBJECTIVE

To define predictors for prolonged ICU stay in order to improve patient outcome and reduce costs.

PATIENTS AND METHODS

Prospective data on 10,759 patients undergoing coronary artery bypass grafting with and without use of cardiopulmonary bypass (coronary artery bypass grafting, CABG; n =8,917; off-pump coronary artery bypass grafting, OPCAB; n =765; minimally invasive direct coronary artery bypass grafting, MIDCAB; n =1,077) between April 1996 and August 2001 were subjected to univariate and, consecutively, to multivariate logistic regression analysis. Prolonged ICU stay was defined as intensive care treatment for three postoperative days and longer.

MEASUREMENTS AND RESULTS

Mean duration of ICU stay was 3.8+/-6.9 days; overall prevalence of prolonged ICU stay was 37.1%. The hospital mortality was 3.5% (ICU > or =3 days: 5.9%; ICU <3 days: 2.0%). Out of 39 selected pre- and intraoperative patient- and treatment-related variables, by univariate analysis, 32 variables having a high association with prolonged ICU stay were identified. Using a stepwise logistic regression model, 20 variables were shown to be independent predictors for prolonged ICU stay. Both OPCAB and MIDCAB surgery were identified as having a significantly lower association with prolonged ICU stay.

CONCLUSION

As prolonged ICU stay is associated with poor patient outcome and increased costs it is of utmost importance to identify patients at a high risk for prolonged ICU stay. More frequent off-pump CABG may optimize patient outcome.

Present practice and development of minimally invasive techniques, imaging and training in European urology: results of a survey of the European Society of Uro-Technology (ESUT)

OBJECTIVES

The European Society of Urological Technology (ESUT) conducted a survey in order to assess and record the current trend between European urologists with regard to the application of new technologies in BPH, stone disease and imaging and to identify differences amongst urologists.

MATERIAL AND METHODS

A total of 854 certified urologists and residents coming from European countries answered the ESUT survey during the XVIth Annual EAU Meeting in Geneva in 2001. The respondents were classified according to the geographical origin (Eastern, Southern and Northern Europe), year of certification (before 1980, and every 5 years hereafter) and power of the department in beds (less than 25, 26-50, and more than 50) in order to identify any differences in the replies mainly due to economical reasons, national or hospital policy and personal attitudes.

RESULTS

According to the replies, in Eastern Europe more procedures related to BPH and stones are performed comparing to Northern and Southern Europe (165.8 versus 77.1 and 100.6/month/department, respectively). However, the Northern European urologists have access to every type of lithotriptor and most of the different minimally invasive treatments for BPH in a higher percentage, followed by the Southern and the Eastern European urologists. The most widespread intracorporeal lithotriptor is the pneumatic and the most common alternative minimally invasive BPH treatment is electrovaporization (80.7% and 45.6%, respectively). Holmium laser is the most frequent choice (40.1%) when the surveyed urologists were asked to choose which of the minimally invasive techniques would like to have access to. In total 79.4% (54.1% alone and 25.3% in collaboration with the radiologists) of the respondents perform the ultrasound studies while the remaining 20.6% declare that only the radiologists do the studies. Of the surveyed urologists, 92.8%, 89.6% and 94.9% are interested in hands-on courses, simulators and live surgery, respectively.

CONCLUSIONS

The data obtained from the 854 surveyed European urologists and residents can be used as a tool to highlight the disparity between European countries and to advance training of European urologists.

Minimally invasive lumbar fusion

STUDY DESIGN

Review article.

OBJECTIVES

To provide an overview of current techniques for minimally invasive lumbar fusion.

SUMMARY OF BACKGROUND DATA

Minimally invasive techniques have revolutionized the management of pathologic conditions in various surgical disciplines. Although these same principles have been used in the treatment of lumbar disc disease for many years, minimally invasive lumbar fusion procedures have only recently been developed. The goals of these procedures are to reduce the approach-related morbidity associated with traditional lumbar fusion, yet allow the surgery to be performed in an effective and safe manner.

METHODS

The authors' clinical experience with minimally invasive lumbar fusion was reviewed, and the pertinent literature was surveyed.

RESULTS

Minimally invasive approaches have been developed for common lumbar procedures such as anterior and posterior interbody fusion, posterolateral onlay fusion, and internal fixation. As with all new surgical techniques, minimally invasive lumbar fusion has a learning curve. As well, there are benefits and disadvantages associated with each technique. However, because these techniques are new and evolving, evidence to support their potential benefits is largely anecdotal. Additionally, there are few long-term studies to document clinical outcomes.

CONCLUSIONS

Preliminary clinical results suggest that minimally invasive lumbar fusion will have a beneficial impact on the care of patients with spinal disorders. Outcome studies with long-term follow-up will be necessary to validate its success and allow minimally invasive lumbar fusion to become more widely accepted.

Minimally invasive parathyroidectomy under local anesthesia

Primary hyperparathyroidism is commonly associated with uniglandular swelling, and thus the lesion has been localized before surgical reduction. Since March 1997, we have performed uniglandular parathyroidectomy under local anesthesia with combined scintigram and ultrasound tomography in patients with primary hyperparathyroidism preoperatively identified for uniglandular swelling. We had seen consecutive 18 patients with primary hyperparathyroidism until April 2001; 15 of those underwent surgical reduction. Postoperative intact PTH value was normalized in 14 patients. The remaining patient, diagnosed with thyroid adenoma, required re-surgery due to proved intake on scintigram a year later. Mean follow-up period is 33 months, and the disease does not relapse. In addition, we removed the swollen gland in two patients with renal hyperparathyroidism under local anesthesia; the disease involved two glands in a patient and one gland in another patient. After surgery, their subjective symptoms including itching and arthralgia were eliminated, and did not relapse at 30 and 14 months, respectively. Minimally invasive parathyroidectomy under local anesthesia might be performed as a same-day surgery, and improve QOL of patients.

Direct mini-incision thyroidectomy

We recently developed a new surgical technique for carrying out thyroidectomy, to minimize surgical invasiveness and improve the cosmetic result. Our procedure differs from conventional thyroidectomy in requiring a 3-cm skin incision and no raising of the skin flap. Since this technique decreased tissue trauma by obviating unnecessary neck exploration, hypesthesia or paresthesia in the neck and discomfort while swallowing, related to a large skin incision and raising of the skin flap, are minimized. Since thyroidectomy is performed after delivering the thyroid gland through the small skin incision, sufficient exposure for dissection of the pretracheal and paratracheal space can be obtained. Therefore, injuring the recurrent laryngeal nerve and the parathyroid gland can be avoided. Although the number of patients that we have treated in this manner is still small, we believe that our new procedure constitutes a useful surgical treatment for patients with thyroid disease.

[Prevalence and preference with regard to various surgical treatments for benign prostatic hypertrophy: a survey for the Japanese endourology and ESWL society member]

BACKGROUND AND PURPOSE

We conducted a questionnaire survey concerning the prevalence and preference with regard to various types of surgical treatment for benign prostatic hypertrophy (BPH), in order to gather preliminary data that may be helpful for standardizing the surgical treatment of BPH.

METHOD

A questionnaire survey was mailed to institutes in which a council member of the Japanese Endourology and ESWL Society was present. The questions dealt with the type and volume of surgical treatment experienced previously, and the treatments which had been performed in each institute during 2000. Preferences concerning cost effectiveness, safety, degree of invasion, efficacy, overall usefulness, and the possibility of prevalence from now on at general hospitals were also asked with regard to each surgical treatment.

RESULTS

Of the 155 institutes to which the questionnaire was sent, 70 responded (45% response rate). TUVP (transurethral vaporization of the prostate by thick-loop) was second to TURP (transurethral resection of the prostate) both regarding the volume of the surgical treatment that had been experienced previously, and the volume that had been performed during 2000. TURP was recognized as the most preferred treatment with regard to both cost effectiveness and overall usefulness, while TURF (transurethral radiofrequency thermotherapy) was preferred both for safety and reduced invasiveness, and open surgery for efficacy. Minimal invasive surgical treatment, such as TUVP, followed by ILCP (interstitial laser coagulation of the prostate) and TUMT (transurethral microwave thermotherapy) was recognized as the most preferable treatment for dealing with the prevalence from now on at general hospitals.

CONCLUSION

Each minimal invasive surgical treatment was recognized as being safer and less invasive, but less effective and less useful compared to TURP. Among these surgical treatments, TUVP by thick-loop was recognized as being second choice to TURP with regard to efficacy and overall usefulness. As a matter of course, it would seem to be essential to evaluate long-term efficacy in addition to both safety and invasiveness when trying to standardize the surgical treatment for BPH.

Factors predicting choice of treatment for menorrhagia in gynaecology outpatient clinics

The aim of this prospective study was to investigate factors predicting choice of treatment for excessive menstrual bleeding, with special emphasis on women's pre-treatment preference. A cohort of women with heavy menstruation and their treatment process in gynaecology outpatient clinics were followed-up for 1yr. A total of 383 35-54-yr-old women attending 14 Finnish hospitals participated. They completed a questionnaire before their first outpatient clinic visit, and postal follow-ups were conducted 3 and 12 months later. Information on treatment(s) during the follow-up was taken from medical records and questionnaires. The choice between hysterectomy and conservative treatments, and fulfillment of pre-treatment preference were the main outcome measures. During the 1-yr follow-up, 51% (n=196) of the women underwent hysterectomy and nine were still awaiting it, 12% (n=44) had a minor surgical procedure, 11% (n=41) had oral medication, 9% (n=33) used a hormonal intrauterine system, and nine women changed preventive method. Forty-two women (11%) reported having had no treatment. Data on previous treatments suggested that conservative treatment modalities were under-used. Most of the treatment decisions were made within the first 3-month period. Women's pre-treatment preference was the strongest predictor of chosen treatment. Unemployment, irregular periods and anxiety decreased the probability of a decision for hysterectomy, while pelvic pain and inconvenience due to bleeding increased it. The treatment plan accorded with pre-treatment preference in 72% of the women preferring hysterectomy and in 74% of those preferring a conservative option.

Minimally invasive surgery training in Canada: a survey of general surgery

BACKGROUND

The purpose of this study was to assess the state of surgical training in minimally invasive surgery (MIS) within Canadian academic surgical departments.

METHODS

A pretested questionnaire was distributed to the general surgery residents of participating Canadian academic surgical departments.

RESULTS

Fourteen of 16 residency programs participated and 235 of 388 residents (60%) responded to the survey. Residents expect to perform both basic (217/235 [92%]) and advanced (123/234 [53%]) MIS procedures on completion of their residency. However, only 41 of 233 (18%) believed that their advanced MIS training would be adequate. On a Likert scale, the most important factors influencing their training included limited advanced case volume (median, 5), limited opportunity in the operating room (OR) (median, 5), lack of attending surgeon interest (median, 4), limited OR time (median, 4), and a lack of surgical department support (median, 4). Residents were concerned about their ability to acquire these skills once they finished their training (median, 4), and 231 of 234 (99%) thought that there was an important role for a MIS surgeon within the academic setting (median, 5).

CONCLUSION

The rapid development of MIS has generated complex issues for resident training within the present Canadian academic surgical environment.

A new method for digital video documentation in surgical procedures and minimally invasive surgery

BACKGROUND

Documentation of surgical procedures is limited to the accuracy of description, which depends on the vocabulary and the descriptive prowess of the surgeon. Even analog video recording could not solve the problem of documentation satisfactorily due to the abundance of recorded material. By capturing the video digitally, most problems are solved in the circumstances described in this article.

METHODS

We developed a cheap and useful digital video capturing system that consists of conventional computer components. Video images and clips can be captured intraoperatively and are immediately available. The system is a commercial personal computer specially configured for digital video capturing and is connected by wire to the video tower. Filming was done with a conventional endoscopic video camera. A total of 65 open and endoscopic procedures were documented in an orthopedic and a thoracic surgery unit. The median number of clips per surgical procedure was 6 (range, 1-17), and the median storage volume was 49 MB (range, 3-360 MB) in compressed form. The median duration of a video clip was 4 min 25 s (range, 45 s to 21 min). Median time for editing a video clip was 12 min for an advanced user (including cutting, title for the movie, and compression). The quality of the clips renders them suitable for presentations.

CONCLUSION

This digital video documentation system allows easy capturing of intraoperative video sequences in high quality. All possibilities of documentation can be performed. With the use of an endoscopic video camera, no compromises with respect to sterility and surgical elbowroom are necessary. The cost is much lower than commercially available systems, and setting changes can be performed easily without trained specialists.

Minimally invasive techniques in common surgical procedures: implications for training

BACKGROUND

Laparoscopic techniques are increasingly used in common surgical procedures. Many of these procedures are used to teach basic surgical trainees (BST) and therefore introduction of these techniques may have implications for training.

AIMS

To establish whether the introduction of laparoscopic techniques reduced the opportunity of BSTs to perform surgical procedures.

METHODS

Patients undergoing hernia repair or appendicectomy in 1991 (when laparoscopy was first introduced) and 1997 (when laparoscopy was readily available) were identified using the Hospital In-Patient Enquiry (HIPE) database. The principal operator and whether the procedure was open or laparoscopic were identified by chart review.

RESULTS

The data showed a 50% reduction in the number of appendicectomies performed by BSTs following the introduction of laparoscopic techniques. The number of hernia repairs performed by BSTs has been preserved but the proportion by BSTs fell from 10 to 6%. The proportion of BST-performed procedures carried out laparoscopically has been reduced compared with the registrar-performed group.

CONCLUSIONS

The use of minimally invasive techniques has had a negative effect on surgical training. Appropriate measures must be taken to minimise this and such measures should include a structured approach to laparoscopic training and greater access to laparoscopic training facilities.

Effects of a moderate dose of alcohol on simulated laparoscopic surgical performance

BACKGROUND

In medicine, there is no professional regulation of the drinking of alcohol, nor a body of experimental evidence on which such regulation might be based. Here we report the acute and longer-term ("hangover") effects of a moderate dose of alcohol on performance, as assessed objectively on a laparoscopic surgical simulator.

METHODS

In a single-blind, experimental study, medical student subjects were assigned randomly to an alcohol (1.05 mg/kg) or a placebo condition (n = 14 in each). The effects of alcohol on performance on the MIST Virtual Reality surgical simulator were examined 60-90 min and 600-630 min (after a night's sleep) following its ingestion. Measures of the number of errors, time taken, hand movement economy, and excessive use of diathermy were recorded.

RESULTS

On each measure, performance was significantly impaired 60-90 min following alcohol ingestion, but there was no hangover effect 600-630 min later, following a night's sleep. This impairment could not be attributed to between-group differences in either predrink performance, expertise or estimated sleep duration during the night preceding the experimental session.

CONCLUSIONS

Simulated surgical performance is impaired severely when estimated blood alcohol concentration (BAC) is just above the UK legal limit for driving. These results contribute new, objective and quantitative evidence to the current debate about the use and misuse of alcohol within the medical profession.

Training the novice in laparoscopy. More challenge is better

BACKGROUND

Virtual reality simulation is effective in training the novice to perform basic laparoscopic skills.

METHODS

Using the Minimally Invasive Surgery Training--Virtual Reality (MIST-VR) trainer, 27 honors high school students were tested at the easy level, prospectively randomized to eight training sessions at the easy (group A, n = 14) or medium (group B, n = 13) level, then retested at the easy level.

RESULTS

Both groups were statistically similar at baseline. All scores improved significantly (50.1% to 81.3%) over the period of training (p < 0.05). Although the group A scores were significantly better than the group B scores throughout training (p < 0.05), on final testing at the easy level, group B surpassed group A for all the tasks except TransferPlace (p = 0.054).

CONCLUSIONS

Virtual simulation is an effective laparoscopic training method for the novice, providing significant improvement in skill levels over a relatively short period. More challenging training seems to predict greater improvement over time and better final skill levels.

Virtual reality as a metric for the assessment of laparoscopic psychomotor skills. Learning curves and reliability measures

BACKGROUND

The objective assessment of the psychomotor skills of surgeons is now a priority; however, this is a difficult task because of measurement difficulties associated with the assessment of surgery in vivo. In this study, virtual reality (VR) was used to overcome these problems.

METHODS

Twelve experienced (>50 minimal-access procedures), 12 inexperienced laparoscopic surgeons (<10 minimal-access procedures), and 12 laparoscopic novices participated in the study. Each subject completed 10 trials on the Minimally Invasive Surgical Trainer; Virtual Reality (MIST VR).

RESULTS

Experienced laparoscopic surgeons performed the tasks significantly (p < 0.01) faster, with less error, more economy in the movement of instruments and the use of diathermy, and with greater consistency in performance. The standardized coefficient alpha for performance measures ranged from a = 0.89 to 0.98, showing high internal measurement consistency. Test-retest reliability ranged from r = 0.96 to r = 0.5.

CONCLUSION

VR is a useful tool for evaluating the psychomotor skills needed to perform laparoscopic surgery.

Comparative study of thyroidectomies. Endoscopic surgery versus conventional open surgery

BACKGROUND

We have performed endoscopic thyroidectomy by an anterior chest approach and by an axillary approach. In this study, we evaluate the efficacy of these two types of endoscopic procedures and conventional open surgery.

METHODS

Each procedure was performed in 15 patients. The degree of surgical invasiveness and the nature of patients' complaints after surgery were compared using results of the operation and a questionnaire.

RESULTS

Although the mean operating time for the endoscopic procedure was significantly longer than for open surgery, there was no postoperative pain difference in the three groups. Three months after surgery, the incidence of swallowing discomfort was higher in the open surgery group than in endoscopic surgery group. All of the patients treated using the axillary approach were satisfied with the cosmetic results. However, three patients (20%) treated using the anterior chest approach and 11 patients (73%; p < 0.01) who underwent open surgery complained about the cosmetic results.

CONCLUSIONS

The incidence of postoperative complaints after endoscopic surgery is significantly lower than after open surgery. Patients treated using the axillary approach can obtain cosmetic results superior to those achieved with other procedures.

Worldwide trends in the surgical treatment of primary hyperparathyroidism in the era of minimally invasive parathyroidectomy

HYPOTHESIS

Minimally invasive surgery for primary hyperparathyroidism has become an accepted part of endocrine surgical practice worldwide.

DESIGN

Survey of members of the International Association of Endocrine Surgeons.

SETTING

Clinical practice of endocrine surgeons worldwide.

MAIN OUTCOME MEASURES

Numbers of parathyroid procedures performed, types of minimally invasive procedures undertaken, and techniques used to ensure completeness of removal of hyperfunctioning parathyroid tissue as reported by the survey respondents.

RESULTS

Of 160 surveys completed, 95 (59%) indicate that the surgeons currently perform minimally invasive parathyroidectomy and use this technique on average for 44% of patients with primary hyperparathyroidism. The most common approach is the focused technique with a small incision, either central or lateral (92% [87 respondents]), followed by a video-assisted technique (22% [21 respondents]), and a true endoscopic technique with gas insufflation (12% [11 respondents]). Techniques used to ensure completeness of resection include the quick intraoperative intact parathyroid hormone assay (68% [65 respondents]), a same-day intact parathyroid hormone assay (17% [16 respondents]), and the nuclear probe (14% [13 respondents]). The number of parathyroidectomies performed worldwide increased from 1727 in 1980 to 6977 in 2000 with the average number per surgeon increasing from 23 in 1980 to 45 in 2000. Geographically, 20 (59%) of 34 surveys from the Americas report the use of minimally invasive parathyroidectomy, 23 (56%) of 41 from the Australasian region, and 34 (49%) of 69 from Europe or the Middle East.

CONCLUSIONS

The number of parathyroidectomies performed for primary hyperparathyroidism has increased worldwide over the past 20 years. More than half of the surgeons responding to the survey perform minimally invasive parathyroidectomy, with the most using the focused small-incision technique.

Endovascular stent grafting versus open surgical operation in patients with infrarenal aortic aneurysms: a propensity score-adjusted analysis

BACKGROUND

Although transfemoral endovascular aneurysm management (TEAM) of infrarenal abdominal aortic aneurysms (AAA) is widely performed, open graft replacement is still considered the standard of care. The aim of this study was to investigate whether clear indications for TEAM can be established in patients with significant comorbidities without investigating differences in relative procedure efficacy or durability.

METHODS AND RESULTS

A propensity score-based analysis of 454 consecutive patients treated electively for AAA from January 1995 through December 2000 was performed. Of those 454 patients, 248 received open surgery and 206 received TEAM. In-hospital mortality rates (MRs) were compared. After adjusting for propensity scores, a Cox proportional hazard model (COX) was employed to test the influence of the respective treatment on postoperative 900-day survival estimates (SEs). Several potential preoperative risk factors were used as covariates. The MR of all patients was 3.7%. Explorative analysis demonstrated that patients treated by TEAM presented with significantly more risk factors. In American Society of Anesthesiologists class IV patients, a significant difference in MR was detected (4.7% for TEAM versus 19.2% for open surgery; P<0.02). After adjusting for the propensity to receive TEAM or open surgery, a regression analysis of survival based on COX revealed predictive influences of impaired kidney (P<0.047) or pulmonary function (P<0.001), increased age (P<0.05), and selection of treatment modality (P<0.002) on SE.

CONCLUSIONS

TEAM represents a less invasive procedure for AAA therapy in patients with significant preoperative risk factors. Especially in geriatric patients with multiple morbidities, TEAM offers a method of therapy with acceptable MRs and SEs, making active treatment possible in otherwise incurable patients.

Coronary artery surgery results 2000

We have reported on changes in the nature and outcome of coronary artery bypass surgery over the past 30 years, focusing on surgery performed last year, from January 1 to December 31, 2000. The operative mortality for patients who underwent only coronary artery bypass surgery was 2.75% in 2000. Mortality for initial elective surgery was 1.73%. These are the best results obtained since surveys were started. The percentage of elderly patients undergoing coronary artery bypass surgery is rising annually. In 2000, 40.8% of patients were aged 70 years or older and 5.3% were aged 80 years or older. Mortality in elderly patients undergoing initial elective surgery is decreasing, with a mortality of 2.5% for patients aged 70 years or older and 2.9% for patients aged 80 years or older. Off-pump coronary artery bypass grafting was performed on 3,356 patients in 2000. Median sternotomy was used in the majority of cases, with 2,988 patients undergoing surgery by this approach. Use of minimally invasive direct coronary artery bypass (MIDCAB) peaked in 1998 but is becoming less common, with only 280 patients undergoing this procedure in 2000.

Six hundred fifty-six consecutive explorations for primary hyperparathyroidism

OBJECTIVE

To review the outcomes of 656 consecutive parathyroid explorations performed by a single surgeon and to compare the results of conventional and minimally invasive parathyroidectomy (MIP) techniques.

SUMMARY BACKGROUND DATA

Traditional surgery for primary hyperparathyroidism (HPTH) involves bilateral cervical exploration, which is usually accomplished under general endotracheal anesthesia. The MIP technique involves preoperative localization with sestamibi scans, surgeon-administered cervical block anesthesia, directed exploration through a small incision, intraoperative rapid parathyroid hormone assay, and discharge within 2 to 3 hours of surgery.

METHODS

Six hundred fifty-six consecutive patients with primary HPTH underwent exploration between January 1990 and March 2001.

RESULTS

MIP was used with ever-increasing frequency beginning in March 1998. Four hundred one procedures (61%) were performed using the standard technique and 255 patients (39%) were selected for MIP. The success rate for the entire series was 98%, with no significant differences comparing traditional and MIP techniques. The overall complication rate of 2.3% reflects 3.0% and 1.2% rates in the standard and MIP groups, respectively. MIP was associated with approximately a 50% reduction in operating time, a sevenfold reduction in length of hospital stay, and a mean cost savings of $2,693 per procedure, which represents nearly a 50% reduction in total hospital charges.

CONCLUSIONS

A dramatic and sustained shift has occurred in the surgical treatment of primary HPTH: MIP has replaced traditional exploration for most patients.

[Ways in which new surgical techniques have influenced the increasing use of cardiosurgery]

BACKGROUND

During the last decade new strategies and equipment have gained popularity in the clinical and experimental setting of cardiac surgery. Little is known about the real impact of these new approaches on the development of heart surgery. The present paper aimed to characterize, through a multicenter evaluation, the state of the art in Italy.

METHODS

A survey of all active heart surgery centers in Italy (both public and private institutions) was conducted through a questionnaire. Diffusion, effectiveness and future perspective of these new surgical techniques were asked. Off-pump coronary artery surgery, myocardial revascularization in patients with low left ventricular ejection fraction, left ventricular surgical remodeling, mitral valve reconstruction, ministernotomic approach in aortic surgery and the use of laser, robots, heart port-access and endoscopy were the strategies under investigation.

RESULTS

The use of laser, heart port-access and endoscopy were considered to have a poor impact due to proved ineffectiveness and/or technical complexity. Indications and long-term outcomes of off-pump coronary artery surgery are still under active debate. The introduction of new prosthetic materials has resulted in the widespread diffusion of mitral valve reconstruction approaches with concomitant widening of the indications. Similarly there is wide consensus on myocardial revascularization in patients with low ejection fraction. Ministernotomic strategies and ventricular remodeling are slowly but progressively gaining acceptance.

CONCLUSIONS

Cardiac surgery in Italy is characterized by a great effort on new research field. Traditional approaches are still preferred unless new techniques have proved effective after strict scientific evaluation.

Development of robotic enhanced endoscopic surgery for the treatment of coronary artery disease

BACKGROUND

The introduction of robotic enhanced surgery demanded stepwise development of performed procedures on the basis of growing experience of the operating team.

METHODS AND RESULTS

Between May 1999 and January 2001, this new wrist-enhanced instrumentation was used in 201 patients (156 men and 45 women, median age 64+/-10.5 years, left ventricular ejection fraction 68+/-12.4%). During the development of robotic enhanced CABG, the patients were divided into 3 groups. Group A (n=156) consisted of patients in whom the robotic system was used to harvesting the left or right internal mammary artery, or both, whereas the anastomoses were performed directly through a small chest incision. In group B (n=37), the harvest of the internal mammary arteries and the coronary anastomoses were performed totally endoscopically. In a third early group C, patient (n=8) were treated with robotic enhanced CABG via a median sternotomy already preoperatively planned, whereas gradual step-by-step application of robotic instrumentation and its feasibility were assessed. The survival rate was 99.4%. One patient (0.6%) died due to pneumonia on postoperative day 16. Conversion rate to median sternotomy was 5%. The left and right internal mammary artery conduits could be successfully harvested in 98% and 100%, respectively. The time of dissection of the left internal mammary artery could be significantly reduced alone by increasing experience. All patients were discharged from the hospital after a mean of 7 days. In 9 patients (4.5%), bleeding required reexploration.

CONCLUSIONS

The introduction of this new surgical tool enables the development of new endoscopic procedures. Our results gained during the development of robotic enhanced CABG motivate us to establish a set standard for the totally endoscopic treatment of patients with 1-vessel coronary artery disease.

The development and implementation of a computerized database for clinical research in minimal access surgery. An international pilot study

BACKGROUND

The measurement of outcomes after minimal access surgery (MAS) relies on the maintenance of an accurate, prospective clinical database. The development of a system for data management often proves to be challenging, expensive, and extremely time-consuming.

METHODS

We developed a computerized relational database for MAS using Microsoft Access 97 to reside on a hospital server, taking advantage of existing network connections, security, and backup systems. The design of the database includes a point-and-click approach with dropdown boxes for diagnoses, procedures, and complications (limited free-text entry). A fundamental feature of this database allows surgeons and surgical trainees to record clinical information at the point and time of data acquisition.

RESULTS

A "beta version" or fully functional draft of the database was presented to a group of surgeons from a variety of specialties (n = 8), and a structured interview based on a questionnaire was used to elicit the surgeon's evaluations of the database. Using the information from the interviews, the database was extensively revised and restructured.

CONCLUSIONS

We have developed a relational database that reflects the needs of surgeons interested in clinical research. This database may serve as a template for other centers. It can be expanded to adopt new procedures or modified for other surgical specialties.

Brain surgery with image guidance: current recommendations based on a 20-year assessment

Image guidance promotes safe and effective surgical management of a wide array of intracranial diseases. To better define the historical importance of image guidance and to assess the relative contribution of each imaging modality to the safety and efficacy of selected procedures, we reviewed our 20-year experience at a single institution. A retrospective review of our departmental surgical records was performed to identify patients who underwent brain surgery with image guidance between January 1979 and January 1999. We identified the use of intraoperative fluoroscopy, endoscopy, computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, and angiography in 7,388 patients. During this 20-year interval, advances in neuroimaging were translated into the operating room environment. Fluoroscopic guidance received the highest overall rating and was deemed critical for the performance of successful transsphenoidal surgery (n = 436) and effective percutaneous trigeminal neuralgia management (n = 1,121). Ultrasound and angiography both had limited roles; the latter was important to successful outcomes in 64 patients undergoing aneurysm management (n = 64) and arteriovenous malformation Gamma Knife radiosurgery (n = 786). Endoscopy also had a small role but had limited cost. Beginning in 1982, a dedicated operating room CT scanner was used during both morphologic and functional stereotactic surgery (n = 1,749). After 1986, MRI was used increasingly in the management of selected functional and tumor cases (n = 337); despite great versatility for patients undergoing Gamma Knife radiosurgery, the costs were relatively high. Frameless neuronavigation (n = 263) had excellent versatility and was relatively low in cost. During the last 20 years, image guidance techniques have facilitated minimally invasive brain surgery at our institution. The relative merits of all these imaging tools depended mostly on their versatility and relative costs. Major centers currently contemplating the incorporation of image guidance into routine brain surgery need not reproduce our own learning curve.

Favorable attitudes toward testing for chromosomal abnormalities via analysis of fetal cells in maternal blood

PURPOSE

The NICHD Fetal Cell Isolation Study (NIFTY) was a multicentered project to isolate fetal cells from maternal blood to detect fetal chromosomal abnormalities. The project included a psychosocial component, which is the basis of this article. We examined the attitudes of high-risk pregnant women toward the availability of a maternal blood test to identify fetal chromosomal abnormalities, how women would respond to hypothetical normal and abnormal maternal blood testing results, and the factors associated with a woman's preference to have an invasive procedure in response to a normal maternal blood test.

METHODS

High-risk pregnant women (N = 854) planning to have prenatal diagnostic invasive testing (amniocentesis or chorionic villus sampling) completed a survey.

RESULTS

The women highly favored maternal blood testing. Almost all women would seek invasive testing after an abnormal blood test. Only half of the women would seek invasive testing after a normal blood test; these women were older, more willing to terminate their pregnancy, and valued the increased accuracy of invasive testing more highly than women who would not have invasive testing after a normal maternal blood test.

CONCLUSIONS

Women having invasive diagnostic testing welcome a noninvasive procedure that uses fetal cells in maternal blood, and its availability would decrease invasive testing by approximately 50%. Research needs to examine the attitudes and anticipated responses of other risk groups as well as the effects of information about maternal blood test sensitivity and specificity on attitudes and responses.

Minimally invasive technique for sural nerve harvesting: technical description and follow-up

OBJECTIVES

To provide instruction and the results of a minimally invasive technique for sural nerve harvesting in preparation for interposition nerve grafting during radical retropubic prostatectomy.

METHODS

Twelve men underwent nerve harvesting performed using a tendon stripper. The short-form McGill Pain Questionnaire was completed preoperatively and at 6 months postoperatively.

RESULTS

No significant morbidity from the leg resulted as a result of the sural nerve harvest. The results of the short-form McGill Pain Questionnaire demonstrated no significant sensory or affective changes in the leg. The average operative time for the entire harvesting procedure, including skin closure, was 15 minutes. The estimated blood loss was less than 5 mL (range 2 to 10). No wound infection or skin erythema was observed. The discharge to home was not delayed compared with the usual length of stay after radical retropubic prostatectomy.

CONCLUSIONS

This minimally invasive sural nerve harvesting technique is easy to perform and has minimal morbidity.

[Off-pump coronary artery bypass grafting: comparison between standard CABG and off-pump CABG]

We have performed 321 cases of coronary artery bypass grafting (CABG), between October 15 1995 and November 20 2000. We have evaluated the operative results of 142 cases (44.2%) of conventional CABG and 179 cases (55.8%) of off-pump CABG performed during this period. The average numbers of bypassed grafts was 3.53 for conventional CABG, and 1.62 for off-pump CABG. The total number of 369 grafts were anastomosed to 501 coronary arteries for conventional CABG, and 283 grafts were anastomosed to 290 coronary arteries for off-pump CABG.

RESULTS

Although two saphenous veins were occluded, the early postoperative patency rate was 100% for conventional CABG using RITA, LITA, GEA and RA. Three site of stenosis in 18 LITAs and 2 in 16 RITAs were recognized in off-pump CABG without the use of stabilizers. One site of stenosis in 130 LITAs and 3 string signs in 44 GEA were recognized in off-pump CABG with the use of stabilizers. Postoperative angiography in 52 off-pump CABG cases at one year later showed no new lesion.

CONCLUSION

The use of stabilizers and LIMA suture enables adaptation of the MIDCAB procedure to a wider range of coronary artery bypass procedures, and a higher graft patency can be expected.

[Is routine application of off-pump coronary artery bypass grafting warranted?]

The limitation and indication of off-pump coronary artery bypass grafting (OPCAB) remain controversial. Since May 1999, we have applied OPCAB for all isolated coronary bypass cases routinely. Intraoperative conversion to CCAB occurred in 8 patients (10.8%). The main reasons for conversion were intramyocardial coronary arteries and arythmia-induced hemodynamic instability in the acute phase of myocardial infarction. We evaluated the results of OPCAB as compared to conventional coronary artery bypass (CCAB) as a historical control. The operative mortality was 1.6% in both groups. Postoperative complications including renal failure and requirements of circulatory support were significantly less in OPCAB. Postoperative max CPK-MB value, the amount of postoperative bleeding and the requirement of transfusion were also significantly less in OPCAB. Only neurological complication in OPCAB was temporary delirium in a high-aged patient, whereas three patients developed neurological complications including permanent stroke in CCAB. Right heart bypass was effectively utilized to maintain hemodynamics and expose the posterior vessels in patients with severely dilated and poorly functioning left ventricle (EF: 24-31%) and a patient with multiple severe stenosis in cerebral arteries. Coronary angiogram performed after the operation demonstrated 94% of graft patency. These results warrant the further application of OPCAB for multivessel surgical revascularization.

[Early results and new indication of the off-pump coronary artery bypass (OPCAB)]

BACKGROUND

The off-Pump coronary artery bypass (OPCAB) has recently gained popularity. However the safety and feasibility of the procedure has not been fully proven especially for unstable myocardial ischemia.

METHODS

Between March 1998 and November 2000, 135 patients with a mean age of 69.7 (41-95) underwent off-pump coronary artery bypass via sternotomy. Eight patients were operated on emergently and 11 were urgently. LV function ranged from 8% to 70%. Eleven patients required preoperative IABP.

RESULTS

All procedures were completed without conversion to cardiopulmonary bypass. The mean number of grafts per patient was 2.8 (range, 1 to 6). Cardiac-related hospital mortality was 2.2% (3/135). Angiographic assessment of grafts demonstrated an overall patency of 98.0%, arterial grafts 98.7% and venous grafts 96.6%. In retrospect, these were equivalent results of conventional coronary artery bypass by the same operator.

CONCLUSION

OPCAB is safe and feasible even with LV dysfunction or unstable myocardial ischemia.

Experience as a factor influencing the indications for laparoscopic colorectal surgery and the results

BACKGROUND

The influence of experience on the results of treatment with laparoscopic surgery is indisputable. The establishment of indications and contraindications is relative, and varies depending on the experience of the surgeon. Learning curves have been described for a number of laparoscopic interventions, in particular laparoscopic cholecystectomy. The current prospective multicenter study investigates, among other things, the interrelation between experience and the results of treatment using laparoscopic colorectal surgery. The study makes no pronouncements on the long-term results achieved in patients with colorectal carcinoma who underwent an operation with curative intent, although relevant data were indeed collected.

RESULTS

Between August 1, 1995 and February 1, 1999, a total of 1,658 patients were recruited to the prospective multicenter study initiated by the Laparoscopic Colorectal Surgery Study Group. To investigate the influence of surgical experience, two groups were formed. Group A comprised all the institutions and surgeons with experience of more than 100 laparoscopic colorectal operations. Group B contained institutions and surgeons with experience of fewer than 100 such interventions. The results of this study clearly show that in Group A, significantly more procedures involving the rectum were performed (26.7% vs 9.5%), and significantly more carcinomas were surgically managed (37.3% vs 17.3%). Despite this significantly higher level of technically difficult procedures in the patient population of group A, which was comparable in terms of age, gender, height, and weight with the patient in group B, the postoperative mortality and morbidity was, with the exception of urinary tract infections, identical between the two groups. Conversion to open surgery was significantly less frequent in group A (4.3% vs 6.9%), and, finally, the duration of the procedures performed by the more experienced surgeons of group A was appreciably shorter than in institutions with a smaller frequency of such operations.

CONCLUSIONS

Laparoscopic colorectal surgery is very demanding, and can be performed with low morbidity and mortality rates only by a surgeon with above-average experience with this type of surgery and a large caseload of laparoscopic colorectal procedures. The learning curve for such procedures is appreciably longer than for other laparoscopic operations. With increasing experience, technically more demanding operations, including radical oncologic rectal laparoscopic procedures, can be performed with appreciably reduced operating times and conversion rates, but with no increase in morbidity or mortality.

New surgical techniques and surgical site infections

Technologic advances in surgery include a trend toward less invasive procedures, driven by potential benefits to patients and by health-care economics. These less invasive procedures provide infection control personnel opportunities for direct involvement in outcomes measurement.

Surgeon predictions on growth of minimal invasive therapy: the difficulty of estimating technologic diffusion

OBJECTIVE

To compare five-year predictions made in 1992 by academic surgeon leaders in UK, US and Canada, with actual experiences in 1997, of increased rates of minimal invasive therapy (MIT) for surgical operations.

METHOD

We compared 1992 predictions of percent of operations done by minimal invasive therapy and length of stay in the US with actual 1997 percents found by literature searches.

RESULTS

We found sufficient data on 12 operations done by MIT in 1997 of the original 34 operations predicted in 1992 by surgeon experts to be to be amenable to this technique. These 12 operations were among the top 20 most commonly performed procedures in 1992 and 1997. Of these 12 operations, ten had 40-60% lower 1997 percentages than predicted, one had about 10% lower rate, and two had 18% and 100% higher rates of MIT than predicted. Overall mean length of stay (LOS) for all 34 study operations fell from 6.8 days in 1992 to 5.2 days in 1997. Mean LOS in 1997 was 2.5 days by MIT and 6.7 days by open technique (OT).

CONCLUSION

Most of the predictions made in 1992 by surgical leaders in Canada, US and UK were incorrect when examined 5 years later. The rate of MIT diffusion and its effect on length of stay were overestimated for most operations, while for two procedures the predictions underestimated extent of diffusion. Also, much of the declines of LOS for surgical care paralleled declines in length of stay for all care, supplemented by the individual contributions of MIT specifically. Relying on expert opinion alone to predict the acceptability, rapidity, scope and extent of technological change is fraught with uncertainty. Unexpected consequences occur when one or a few parts of complex systems are changed. This is a particular problem when predictions are a main basis for informed decision making in the absence of any supporting data from appropriately designed empirical or controlled study.

Standard coronary artery bypass grafting and beating heart bypass. Indications and long-term results

OBJECTIVES AND METHOD

We have performed 225 cases of coronary artery bypass grafting (CABG), between October 15 1995 and September 8 1999. We have evaluated the operative results of 121 cases (53.8%) of conventional CABG and 104 cases (46.2%) of minimally invasive coronary artery bypass grafting performed during this period. The average numbers of bypassed grafts was 3.45 for conventional CABG, and 1.41 for minimally invasive coronary artery bypass grafting. Sixty-seven right internal thoracic arteries, 145 left internal thoracic arteries, 71 gastroepiploic arteries, 38 radial arteries and 12 saphenous veins were used for conventional CABG, and 29 right internal thoracic arteries, 81 left internal thoracic arteries, 18 gastroepiploic arteries, 3 radial arteries, 10 saphenous veins and 2 inferior epigastric arteries were used for minimally invasive coronary artery bypass grafting. The total number of 303 grafts were anastomosed to 417 coronary arteries for conventional CABG, and 143 grafts were anastomosed to 147 coronary arteries for minimally invasive coronary artery bypass grafting.

RESULTS

Although two saphenous veins were occluded, the early postoperative patency rate was 100% for conventional CABG using right internal thoracic arteries, left internal thoracic arteries, gastroepiploic arteries and radial arteries. Three site of stenosis in 18 left internal thoracic arteries and 2 in 16 right internal thoracic arteries were recognized in minimally invasive coronary artery bypass grafting without the use of stabilizers. One site of stenosis in 63 left internal thoracic arteries was recognized in minimally invasive coronary artery bypass grafting with the use of stabilizers.

CONCLUSION

The use of stabilizers enables adaptation of the minimally invasive coronary artery bypass grafting procedure to a wider range of coronary artery bypass procedures, and a higher graft patency can be expected.

Minimally invasive direct cardiac massage versus closed-chest cardiopulmonary resuscitation in a porcine model of prolonged ventricular fibrillation cardiac arrest

Open chest cardiac massage has been shown to be superior to closed-chest cardiopulmonary resuscitation for both hemodynamics produced during resuscitation and ultimate resuscitation success. The inexperience of many rescuers with emergency thoracotomy, along with the associated morbidity contributes to the continued reluctance in the use of invasive cardiopulmonary resuscitation techniques. A device has been developed for performing 'minimally invasive' direct cardiac massage. This technique was compared to standard closed-chest CPR for resuscitation results in 20 swine during prolonged ventricular fibrillation cardiac arrest. Minimally invasive direct cardiac massage was superior to closed-chest CPR for return of spontaneous circulation (7/10 vs. 2/10; P<0.02) and coronary perfusion pressure at 30 min of CPR (17+/-9 vs. 6+/-6 mmHg; P<0.05). No significant injuries altering outcome were found with the invasive device. Throughout most of the time course of the study no significant differences in end-tidal expired carbon dioxide levels were noted. Nor were there any differences in 24-h survival. Improvements in assuring proper placement of the device on the epicardium should make this technique a potent advanced cardiac life support adjunct.