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Tjeertes EKM, Simoncelli TFW, van den Enden AJM, Mattace-Raso FUS, Stolker RJ, Hoeks SE. Perioperative outcome, long-term mortality and time trends in elderly patients undergoing low-, intermediate- or major non-cardiac surgery. Aging Clin Exp Res 2024; 36:64. [PMID: 38462583 PMCID: PMC10925572 DOI: 10.1007/s40520-024-02717-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/31/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Decision-making whether older patients benefit from surgery can be a difficult task. This report investigates characteristics and outcomes of a large cohort of inpatients, aged 80 years and over, undergoing non-cardiac surgery. METHODS This observational study was performed at a tertiary university medical centre in the Netherlands. Patients of 80 years or older undergoing elective or urgent surgery from January 2004 to June 2017 were included. Outcomes were length of stay, discharge destination, 30-day and long-term mortality. Patients were divided into low-, intermediate and high-risk surgery subgroups. Univariable and multivariable logistic regression were used to evaluate the association of risk factors and outcomes. Secondary outcomes were time trends, assessed with Mantel-Haenszel chi-square test. RESULTS Data of 8251 patients, undergoing 19,027 surgical interventions were collected from the patients' medical record. 7032 primary procedures were suitable for analyses. Median LOS was 3 days in the low-risk group, compared to six in the intermediate- and ten in the high-risk group. Median LOS of the total cohort decreased from 5.8 days (IQR 1.9-14.5) in 2004-2007 to 4.6 days (IQR 1.9-9.0) in 2016-2017. Three quarters of patients were discharged to their home. Postoperative 30-day mortality in the low-risk group was 2.3%. In the overall population 30-day mortality was high and constant during the study period (6.7%, ranging from 4.2 to 8.4%). CONCLUSION Patients should not be withheld surgery solely based on their age. However, even for low-risk surgery, the mortality rate of more than 2% is substantial. Deciding whether older patients benefit from surgery should be based on the understanding of individual risks, patients' wishes and a patient-centred plan.
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Affiliation(s)
- E K M Tjeertes
- Department of Anesthesiology, Erasmus MC University Medical Center, PO BOX 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Anesthesiology, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - T F W Simoncelli
- Department of Anesthesiology, Erasmus MC University Medical Center, PO BOX 2040, 3000 CA, Rotterdam, The Netherlands
| | - A J M van den Enden
- Department of Anesthesiology, Erasmus MC University Medical Center, PO BOX 2040, 3000 CA, Rotterdam, The Netherlands
| | - F U S Mattace-Raso
- Division of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - R J Stolker
- Department of Anesthesiology, Erasmus MC University Medical Center, PO BOX 2040, 3000 CA, Rotterdam, The Netherlands
| | - S E Hoeks
- Department of Anesthesiology, Erasmus MC University Medical Center, PO BOX 2040, 3000 CA, Rotterdam, The Netherlands.
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Vereen MS, Harms F, Stolker RJ, Dirckx M. Liposomal bupivacaine for ultrasound-guided rectus sheath blocks after midline laparotomy. Anaesth Rep 2024; 12:e12284. [PMID: 38455713 PMCID: PMC10918720 DOI: 10.1002/anr3.12284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 03/09/2024] Open
Abstract
Optimal pain management after open abdominal surgery is essential but can be difficult to achieve. The effects of inadequate analgesia go beyond the first few postoperative days; severe acute postoperative pain may contribute to the development of chronic postsurgical pain. Thoracic epidural analgesia is a traditional approach to the management of acute pain after open abdominal surgery but has multiple possible contraindications and can be technically challenging. In our hospital, we typically offer ultrasound-guided rectus sheath blocks with catheters when epidural analgesia is not feasible. However, the recent registration of long-acting liposomal bupivacaine in the Netherlands as well as logistical and equipment-related issues have led us to consider liposomal bupivacaine as an alternative to the use of catheters. Here, we present a short case series to describe our first clinical experiences with the use of liposomal bupivacaine in ultrasound-guided rectus sheath blocks after midline laparotomy for three patients in whom epidural insertion was contraindicated.
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Affiliation(s)
- M. S. Vereen
- Department of AnaesthesiaErasmus Medical CentreRotterdamThe Netherlands
| | - F. Harms
- Department of AnaesthesiaErasmus Medical CentreRotterdamThe Netherlands
| | - R. J. Stolker
- Department of AnaesthesiaErasmus Medical CentreRotterdamThe Netherlands
| | - M. Dirckx
- Department of AnaesthesiaErasmus Medical CentreRotterdamThe Netherlands
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Schluep M, Endeman H, Gravesteijn BY, Kuijs C, Blans MJ, van den Bogaard B, Van Gemert AWMMK, Hukshorn CJ, van der Meer BJM, Knook AHM, van Melsen T, Peters R, Simons KS, Spijkers G, Vermeijden JW, Wils EJ, Stolker RJ, Hoeks SE. In-depth assessment of health-related quality of life after in-hospital cardiac arrest. J Crit Care 2021; 68:22-30. [PMID: 34856490 DOI: 10.1016/j.jcrc.2021.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/11/2021] [Accepted: 11/13/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Evidence on physical and psychological well-being of in-hospital cardiac arrest (IHCA) survivors is scarce. The aim of this study is to describe long-term health-related quality of life (HRQoL), functional independence and psychological distress 3 and 12 months post-IHCA. METHODS A multicenter prospective cohort study in 25 hospitals between January 2017 - May 2018. Adult IHCA survivors were included. HRQoL (EQ-5D-5L, SF-12), psychological distress (HADS, CSI) and functional independence (mRS) were assessed at 3 and 12 months post-IHCA. RESULTS At 3-month follow-up 136 of 212 survivors responded to the questionnaire and at 12 months 110 of 198 responded. The median (IQR) EQ-utility Index score was 0.77 (0.65-0.87) at 3 months and 0.81 (0.70-0.91) at 12 months. At 3 months, patients reported a median SF-12 (IQR) physical component scale (PCS) of 38.9 (32.8-46.5) and mental component scale (MCS) of 43.5 (34.0-39.7) and at 12 months a PCS of 43.1 (34.6-52.3) and MCS 46.9 (38.5-54.5). DISCUSSION Using various tools most IHCA survivors report an acceptable HRQoL and a substantial part experiences lower HRQoL compared to population norms. Our data suggest that younger (male) patients and those with poor functional status prior to admission are at highest risk of impaired HRQoL.
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Affiliation(s)
- M Schluep
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - H Endeman
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - B Y Gravesteijn
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - C Kuijs
- Department of Intensive Care Medicine, Maasstad Hospital, Rotterdam, the Netherlands; Resuscitation Committee, Maasstad Hospital, Rotterdam, the Netherlands
| | - M J Blans
- Department of Intensive Care Medicine, Rijnstate Hospital, Arnhem, the Netherlands
| | - B van den Bogaard
- Department of Intensive Care Medicine, OLVG, Amsterdam, the Netherlands
| | | | - C J Hukshorn
- Department of Intensive Care Medicine, Isala Hospital, Zwolle, the Netherlands
| | | | - A H M Knook
- Department of Intensive Care Medicine, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - T van Melsen
- Department of Intensive Care Medicine, Haaglanden Medisch Centrum, The Hague, the Netherlands
| | - R Peters
- Department of Cardiology, Tergooi Hospital, Hilversum, the Netherlands
| | - K S Simons
- Department of Intensive Care Medicine, Jeroen Bosch Hospital, 's Hertogenbosch, the Netherlands
| | - G Spijkers
- Department of Hospital Medicine, ZorgSaam Zeeuws-Vlaanderen, Terneuzen, the Netherlands
| | - J W Vermeijden
- Department of Intensive Care Medicine, Medisch Spectrum Twente, Enschede, the Netherlands
| | - E-J Wils
- Department of Intensive Care Medicine, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - R J Stolker
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - S E Hoeks
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, the Netherlands
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Gravesteijn BY, Schluep M, Lingsma HF, Stolker RJ, Endeman H, Hoeks SE. Between-centre differences in care for in-hospital cardiac arrest: a prospective cohort study. Crit Care 2021; 25:329. [PMID: 34507601 PMCID: PMC8431928 DOI: 10.1186/s13054-021-03754-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Survival after in-hospital cardiac arrest is poor, but current literature shows substantial heterogeneity in reported survival rates. This study aims to evaluate care for patients suffering in-hospital cardiac arrest (IHCA) in the Netherlands by assessing between-hospital heterogeneity in outcomes and to explain this heterogeneity stemming from differences in case-mix or differences in quality of care. METHODS A prospective multicentre study was conducted comprising 14 centres. All IHCA patients were included. The adjusted variation in structure and process indicators of quality of care and outcomes (in-hospital mortality and cerebral performance category [CPC] scale) was assessed with mixed effects regression with centre as random intercept. Variation was quantified using the median odds ratio (MOR), representing the expected odds ratio for poor outcome between two randomly picked centres. RESULTS After excluding centres with less than 10 inclusions (2 centres), 701 patients were included of whom, 218 (32%) survived to hospital discharge. The unadjusted and case-mix adjusted MOR for mortality was 1.19 and 1.05, respectively. The unadjusted and adjusted MOR for CPC score was 1.24 and 1.19, respectively. In hospitals where personnel received cardiopulmonary resuscitation (CPR) training twice per year, 183 (64.7%) versus 290 (71.4%) patients died or were in a vegetative state, and 59 (20.8%) versus 68 (16.7%) patients showed full recovery (p < 0.001). CONCLUSION In the Netherlands, survival after IHCA is relatively high and between-centre differences in outcomes are small. The existing differences in survival are mainly attributable to differences in case-mix. Variation in neurological outcome is less attributable to case-mix.
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Affiliation(s)
- B Y Gravesteijn
- Department of Public Health, Erasmus University Medical Center, Postbus, 3000 CA, Rotterdam, The Netherlands.
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - M Schluep
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - H F Lingsma
- Department of Public Health, Erasmus University Medical Center, Postbus, 3000 CA, Rotterdam, The Netherlands
| | - R J Stolker
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - H Endeman
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - S E Hoeks
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Koning MV, de Vlieger R, Teunissen AJW, Gan M, Ruijgrok EJ, de Graaff JC, Koopman JSHA, Stolker RJ. The effect of intrathecal bupivacaine/morphine on quality of recovery in robot-assisted radical prostatectomy: a randomised controlled trial. Anaesthesia 2019; 75:599-608. [PMID: 31845316 PMCID: PMC7187216 DOI: 10.1111/anae.14922] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2019] [Indexed: 11/30/2022]
Abstract
Robot‐assisted radical prostatectomy causes discomfort in the immediate postoperative period. This randomised controlled trial investigated if intrathecal bupivacaine/morphine, in addition to general anaesthesia, could be beneficial for the postoperative quality of recovery. One hundred and fifty‐five patients were randomly allocated to an intervention group that received intrathecal 12.5 mg bupivacaine/300 μg morphine (20% dose reduction in patients > 75 years) or a control group receiving a subcutaneous sham injection and an intravenous loading dose of 0.1 mg.kg−1 morphine. Both groups received standardised general anaesthesia and the same postoperative analgesic regimen. The primary outcome was a decrease in the Quality of Recovery‐15 (QoR‐15) questionnaire score on postoperative day 1. The intervention group (n = 76) had less reduction in QoR‐15 on postoperative day 1; median (IQR [range]) 10% (1–8 [−60% to 50%]) vs. 13% (5–24 [−6% to 50%]), p = 0.019, and used less morphine during the admission; 2 mg (1–7 [0–41 mg]) vs. 15 mg (12–20 [8–61 mg]), p < 0.001. Furthermore, they perceived lower pain scores during exertion; numeric rating scale (NRS) 3 (1–6 [0–9]) vs. 5 (3–7 [0–9]), p = 0.001; less bladder spasms (NRS 1 (0–2 [0–10]) vs. 2 (0–5 [0–10]), p = 0.001 and less sedation; NRS 2 (0–3 [0–10]) vs. 3 (2–6 [0–10]), p = 0.005. Moreover, the intervention group used less rescue medication. Pruritus was more severe in the intervention group; NRS 4 (1–7 [0–10]) vs. 0 (0–1 [0–10]), p = 0.000. We conclude that despite a modest increase in the incidence of pruritus, multimodal pain management with intrathecal bupivacaine/morphine remains a viable option for robot‐assisted radical prostatectomy.
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Affiliation(s)
- M V Koning
- Department of Anaesthesiology, Erasmus Medical Centre, University Medical Centre Rotterdam, the Netherlands.,Department of Anaesthesiology and Critical Care, Rijnstate Hospital, Arnhem, the Netherlands
| | - R de Vlieger
- Department of Anaesthesiology, Erasmus Medical Centre, University Medical Centre Rotterdam, the Netherlands
| | - A J W Teunissen
- Department of Anaesthesiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - M Gan
- Department of Urology, Maasstad Hospital, Rotterdam, the Netherlands
| | - E J Ruijgrok
- Department of Hospital Pharmacy, Erasmus Medical Centre, University Medical Centre Rotterdam, the Netherlands
| | - J C de Graaff
- Department of Anaesthesiology, Erasmus Medical Centre, University Medical Centre Rotterdam, the Netherlands
| | - J S H A Koopman
- Department of Anaesthesiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - R J Stolker
- Department of Anaesthesiology, Erasmus Medical Centre, University Medical Centre Rotterdam, the Netherlands
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Calvache JA, Stolker RJ, Klimek M. Rethinking Evidence-Based Medicine in the perioperative safety scenario. Br J Anaesth 2019; 123:e163-e164. [PMID: 31133286 DOI: 10.1016/j.bja.2019.04.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 10/26/2022] Open
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Barker EJ, Valentijn TM, Van De Luijtgaarden KM, Hoeks SE, Voute MT, Goncalves FB, Verhagen HJ, Stolker RJ. Type 2 Diabetes Mellitus, Independent of Insulin Use, is Associated with an Increased Risk of Cardiac Complications after Vascular Surgery. Anaesth Intensive Care 2019; 41:584-90. [DOI: 10.1177/0310057x1304100515] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- E. J. Barker
- Departments of Anaesthesiology and Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
- Departments of Anesthesiology and Vascular Surgery
| | - T. M. Valentijn
- Departments of Anaesthesiology and Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Anaesthesiology
| | - K. M. Van De Luijtgaarden
- Departments of Anaesthesiology and Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Anaesthesiology
| | - S. E. Hoeks
- Departments of Anaesthesiology and Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Anaesthesiology
| | - M. T. Voute
- Departments of Anaesthesiology and Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Vascular Surgery
| | - F. B. Goncalves
- Departments of Anaesthesiology and Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Vascular Surgery
| | - H. J. Verhagen
- Departments of Anaesthesiology and Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Vascular Surgery
| | - R. J. Stolker
- Departments of Anaesthesiology and Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Anaesthesiology
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Gravesteijn BY, Keizer ME, Vincent AJPE, Schouten JW, Stolker RJ, Klimek M. Awake craniotomy versus craniotomy under general anesthesia for the surgical treatment of insular glioma: choices and outcomes. Neurol Res 2017; 40:87-96. [DOI: 10.1080/01616412.2017.1402147] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- B. Y. Gravesteijn
- Department of Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
| | - M. E. Keizer
- Department of Neurosurgery, Erasmus MC, Rotterdam, The Netherlands
| | | | - J. W. Schouten
- Department of Neurosurgery, Erasmus MC, Rotterdam, The Netherlands
| | - R. J. Stolker
- Department of Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
| | - M. Klimek
- Department of Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
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9
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Tjeertes EKM, Ultee KHJ, Stolker RJ, Verhagen HJM, Bastos Gonçalves FM, Hoofwijk AGM, Hoeks SE. Perioperative Complications are Associated With Adverse Long-Term Prognosis and Affect the Cause of Death After General Surgery. World J Surg 2017; 40:2581-2590. [PMID: 27302465 PMCID: PMC5073115 DOI: 10.1007/s00268-016-3600-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND It is unclear how mortality and causes of death vary between patients and surgical procedures and how occurrence of postoperative complications is associated with prognosis. This study describes long-term mortality rates and causes of death in a general surgical population. Furthermore, we explore the effect of postoperative complications on mortality. METHODS A single-centre analysis of postoperative complications, with mortality as primary endpoint, was conducted in 4479 patients undergoing surgery. We applied univariate and multivariable regression models to analyse the effect of risk factors, including surgical risk and postoperative complications, on mortality. Causes of death were also explored. RESULTS 75 patients (1.7 %) died within 30 days after surgery and 730 patients (16.3 %) died during a median follow-up of 6.3 years (IQR 5.8-6.8). Significant differences in long-term mortality were observed with worst outcome for patients undergoing high-risk vascular surgery (HR 1.5; 95 % CI 1.2-1.9). When looking at causes of death, high-risk surgery was associated with a twofold higher risk of cardiovascular death (HR 1.9; 95 % CI 1.2-3.1), whereas the intermediate-risk group had a higher risk of dying from cancer-related causes (HR 1.5; 95 % CI 1.1-2.0). Occurrence of complications-particularly of cardiovascular nature- was associated with worse survival (HR 1.9; 95 % CI 1.3-2.7). CONCLUSION High-risk vascular surgery and occurrence of postoperative complications are important predictors of late mortality. Further focus on these groups of patients can contribute to reduced morbidity. Improvement in quality of care should be aimed at preventing postoperative complications and thus a better outcome in a general surgical population.
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Affiliation(s)
- Elke K M Tjeertes
- Department of Anesthesiology, Erasmus University Medical Centre, Room H-1273, PO Box 2040 3000, CA, Rotterdam, The Netherlands.
| | - K H J Ultee
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - R J Stolker
- Department of Anesthesiology, Erasmus University Medical Centre, Room H-1273, PO Box 2040 3000, CA, Rotterdam, The Netherlands
| | - H J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | | | - A G M Hoofwijk
- Department of Surgery, Zuyderland Medical Centre, Sittard, The Netherlands
| | - S E Hoeks
- Department of Anesthesiology, Erasmus University Medical Centre, Room H-1273, PO Box 2040 3000, CA, Rotterdam, The Netherlands
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Moors XRJ, Rijs K, Den Hartog D, Stolker RJ. Pediatric out-of-hospital cardiopulmonary resuscitation by helicopter emergency medical service, does it has added value compared to regular emergency medical service? Eur J Trauma Emerg Surg 2017; 44:407-410. [PMID: 28711949 PMCID: PMC6002453 DOI: 10.1007/s00068-017-0815-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 07/11/2017] [Indexed: 11/30/2022]
Abstract
Purpose To determine the outcome of out-of-hospital (OOH) cardiopulmonary resuscitation (CPR) and the advanced life support (ALS) procedures provided in pediatrics by the Rotterdam Helicopter Emergency Medical Service (HEMS) Methods Retrospective evaluation of all pediatric (0–17 years) OOH cardiopulmonary arrests within a 6-year period and attended by the Rotterdam HEMS team. Results There were 201 OOH CPRs from October 2008 until October 2014. Endotracheal intubation was performed in 164 cases and done by HEMS in 104 patients (63%), intraosseous/intravenous cannulation 43/27 times, and additional medication given by HEMS in 70 patients (35%). The overall survival rate for OOH CPR was 15%, but in trauma was low. Twenty-seven of the 29 pediatric patients who survived until discharge are neurological well. Although the Dutch nationwide ambulance protocol states intubation, intravenous, or intraosseal excess and medication, in many patients, only HEMS provided additional ALS care. Conclusion The HEMS brings essential medical expertise in the field not provided by regular emergency medical service. HEMS provide a significant quantity of procedures, obviously needed by the OOH CPR of a pediatric patient.
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Affiliation(s)
- X R J Moors
- Department of Pediatric Anesthesiology, Erasmus MC, University Medical Center Rotterdam-Sophia Children's Hospital, P.O. Box 2060, 3015 CN, Rotterdam, The Netherlands. .,HEMS, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - K Rijs
- Department of Pediatric Anesthesiology, Erasmus MC, University Medical Center Rotterdam-Sophia Children's Hospital, P.O. Box 2060, 3015 CN, Rotterdam, The Netherlands
| | - D Den Hartog
- Department of Surgery-Traumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - R J Stolker
- Department of Pediatric Anesthesiology, Erasmus MC, University Medical Center Rotterdam-Sophia Children's Hospital, P.O. Box 2060, 3015 CN, Rotterdam, The Netherlands
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van de Luijtgaarden KM, Bastos Gonçalves F, Hoeks SE, Blankensteijn JD, Böckler D, Stolker RJ, Verhagen HJM. Higher 30 Day Mortality in Patients with Familial Abdominal Aortic Aneurysm after EVAR. Eur J Vasc Endovasc Surg 2017; 54:142-149. [PMID: 28579278 DOI: 10.1016/j.ejvs.2017.04.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 04/24/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine the influence of a positive family history for aneurysms on clinical success and mortality after endovascular aneurysm repair (EVAR). METHODS From 2009 to 2011, 1262 patients with abdominal aortic aneurysms (AAA) treated by EVAR were enrolled in a prospective, industry sponsored clinical registry ENGAGE. Patients were classified into familial and sporadic AAA patients according to baseline clinical reports. Clinical characteristics, aneurysm morphology, and follow-up were registered. The primary endpoint was clinical success after EVAR, a composite of technical success and freedom from the following complications: AAA increase >5 mm, type I and III endoleak, rupture, conversion, secondary procedures, migration, and occlusion. Secondary endpoints were the individual components of clinical success, 30 day mortality, and aneurysm related and all cause mortality. RESULTS Of the 1262 AAA patients (89.5% male and mean age 73.1 years), 86 patients (6.8%) reported a positive family history and were classified as familial AAA. Duration of follow-up was 4.4 ± 1.7 years. Patients with familial AAA were more often female (18.6% vs. 9.9%, p = .012). No difference was observed in aneurysm morphology. There was no significant difference in clinical success between patients with familial and sporadic AAA (72.1% vs. 79.3%, p=.116). Familial AAA patients had a higher 30 day mortality after EVAR (4.7% vs. 1.0%, adjusted HR 5.7, 1.8-17.9, p = .003) as well as aneurysm related mortality (5.8% vs. 1.3%, adjusted HR 5.4, 1.9-14.9, p = .001), while no difference was observed in all cause mortality (19.8% vs. 24.3%, adjusted HR 0.8, 0.5-1.4, p = .501). CONCLUSIONS The current study shows a higher 30 day mortality after EVAR in familial AAA patients. Future studies should determine the role of family history in AAA treatment, suitability for endovascular or open repair, and on adaptation of post-operative surveillance. For the time being, patients with familial forms of AAA should be considered at higher risk for EVAR and warrant extra vigilance.
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Affiliation(s)
- K M van de Luijtgaarden
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands; Department of Anesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands; Department of Clinical Genetics, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - F Bastos Gonçalves
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands; Department of Angiology and Vascular Surgery, Hospital de Santa Marta, CHLC & NOVA Medical School, Lisbon, Portugal
| | - S E Hoeks
- Department of Anesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - J D Blankensteijn
- Department of Vascular Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - D Böckler
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - R J Stolker
- Department of Anesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - H J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands.
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Tjeertes EKM, Hoeks SE, Beks SBJC, Valentijn TM, Hoofwijk AGM, Stolker RJ. Erratum to: Obesity--a risk factor for postoperative complications in general surgery? BMC Anesthesiol 2015; 15:155. [PMID: 26503436 PMCID: PMC4620626 DOI: 10.1186/s12871-015-0136-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 10/20/2015] [Indexed: 11/28/2022] Open
Affiliation(s)
- E K M Tjeertes
- Department of anesthesiology, Erasmus University Medical Centre, Room H-1273, Rotterdam, CA, The Netherlands.
| | - S E Hoeks
- Department of anesthesiology, Erasmus University Medical Centre, Room H-1273, Rotterdam, CA, The Netherlands
| | - S B J C Beks
- Department of surgery, Orbis Medical Centre, Sittard, The Netherlands
| | - T M Valentijn
- Department of anesthesiology, Erasmus University Medical Centre, Room H-1273, Rotterdam, CA, The Netherlands
| | - A G M Hoofwijk
- Department of surgery, Orbis Medical Centre, Sittard, The Netherlands
| | - R J Stolker
- Department of anesthesiology, Erasmus University Medical Centre, Room H-1273, Rotterdam, CA, The Netherlands
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Tjeertes EKM, Tjeertes EEKM, Hoeks SE, Hoeks SSE, Beks SBJ, Beks SSBJC, Valentijn TM, Valentijn TTM, Hoofwijk AGM, Hoofwijk AAGM, Stolker RJ, Stolker RJRJ. Obesity--a risk factor for postoperative complications in general surgery? BMC Anesthesiol 2015; 15:112. [PMID: 26228844 PMCID: PMC4520073 DOI: 10.1186/s12871-015-0096-7] [Citation(s) in RCA: 167] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 07/22/2015] [Indexed: 02/07/2023] Open
Abstract
Background Obesity is generally believed to be a risk factor for the development of postoperative complications. Although being obese is associated with medical hazards, recent literature shows no convincing data to support this assumption. Moreover a paradox between body mass index and survival is described. This study was designed to determine influence of body mass index on postoperative complications and long-term survival after surgery. Methods A single-centre prospective analysis of postoperative complications in 4293 patients undergoing general surgery was conducted, with a median follow-up time of 6.3 years. We analyzed the impact of bodyweight on postoperative morbidity and mortality, using univariate and multivariate regression models. Results The obese had more concomitant diseases, increased risk of wound infection, greater intraoperative blood loss and a longer operation time. Being underweight was associated with a higher risk of complications, although not significant in adjusted analysis. Multivariate regression analysis demonstrated that underweight patients had worse outcome (HR 2.1; 95 % CI 1.4-3.0), whereas being overweight (HR 0.6; 95 % CI 0.5–0.8) or obese (HR 0.7; 95 % CI 0.6–0.9) was associated with improved survival. Conclusion Obesity alone is a significant risk factor for wound infection, more surgical blood loss and a longer operation time. Being obese is associated with improved long-term survival, validating the obesity paradox. We also found that complication and mortality rates are significantly worse for underweight patients. Our findings suggest that a tendency to regard obesity as a major risk factor in general surgery is not justified. It is the underweight patient who is most at risk of major postoperative complications, including long-term mortality. Electronic supplementary material The online version of this article (doi:10.1186/s12871-015-0096-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Elke E K M Tjeertes
- Department of anesthesiology, Erasmus University Medical Centre, Room H-1273, PO Box 2040, 3000, CA, Rotterdam, The Netherlands.
| | | | - Sanne S E Hoeks
- Department of anesthesiology, Erasmus University Medical Centre, Room H-1273, PO Box 2040, 3000, CA, Rotterdam, The Netherlands
| | | | | | | | - Tabita T M Valentijn
- Department of anesthesiology, Erasmus University Medical Centre, Room H-1273, PO Box 2040, 3000, CA, Rotterdam, The Netherlands
| | | | | | - R J Stolker
- Department of anesthesiology, Erasmus University Medical Centre, Room H-1273, PO Box 2040, 3000, CA, Rotterdam, The Netherlands
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Rieff EA, Stolker RJ, Koning J, de Hingh IHJT, Buise MP. Postoperative care after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy procedures. Anaesth Intensive Care 2015; 43:532-533. [PMID: 26099773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Zarroy O, Hoeks SE, Stolker RJ, Van Lier F. Postoperative hemoglobin levels and their association with myocardial ischemia in non-cardiac surgical patients. Minerva Anestesiol 2014; 80:625. [PMID: 24584278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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16
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Bastos Gonçalves F, Baderkhan H, Verhagen HJM, Wanhainen A, Björck M, Stolker RJ, Hoeks SE, Mani K. Early sac shrinkage predicts a low risk of late complications after endovascular aortic aneurysm repair. Br J Surg 2014; 101:802-10. [PMID: 24752772 PMCID: PMC4164270 DOI: 10.1002/bjs.9516] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2014] [Indexed: 11/15/2022]
Abstract
Background Aneurysm shrinkage has been proposed as a marker of successful endovascular aneurysm repair (EVAR). Patients with early postoperative shrinkage may experience fewer subsequent complications, and consequently require less intensive surveillance. Methods Patients undergoing EVAR from 2000 to 2011 at three vascular centres (in 2 countries), who had two imaging examinations (postoperative and after 6–18 months), were included. Maximum diameter, complications and secondary interventions during follow-up were registered. Patients were categorized according to early sac dynamics. The primary endpoint was freedom from late complications. Secondary endpoints were freedom from secondary intervention, postimplant rupture and direct (type I/III) endoleaks. Results Some 597 EVARs (71·1 per cent of all EVARs) were included. No shrinkage was observed in 284 patients (47·6 per cent), moderate shrinkage (5–9 mm) in 142 (23·8 per cent) and major shrinkage (at least 10 mm) in 171 patients (28·6 per cent). Four years after the index imaging, the rate of freedom from complications was 84·3 (95 per cent confidence interval 78·7 to 89·8), 88·1 (80·6 to 95·5) and 94·4 (90·1 to 98·7) per cent respectively. No shrinkage was an independent risk factor for late complications compared with major shrinkage (hazard ratio (HR) 3·11; P < 0·001). Moderate compared with major shrinkage (HR 2·10; P = 0·022), early postoperative complications (HR 3·34; P < 0·001) and increasing abdominal aortic aneurysm baseline diameter (HR 1·02; P = 0·001) were also risk factors for late complications. Freedom from secondary interventions and direct endoleaks was greater for patients with major sac shrinkage. Conclusion Early change in aneurysm sac diameter is a strong predictor of late complications after EVAR. Patients with major sac shrinkage have a very low risk of complications for up to 5 years. This parameter may be used to tailor postoperative surveillance.
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Affiliation(s)
- F Bastos Gonçalves
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands; Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
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Bakker EJ, Valentijn TM, van de Luijtgaarden KM, Hoeks SE, Voute MT, Goncalves FB, Verhagen HJ, Stolker RJ. Reply: To PMID 23977908. Anaesth Intensive Care 2014; 42:138. [PMID: 24471677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Opstelten W, van Wijck AJM, Moons KGM, van Essen GA, Stolker RJ, Kalkman CJ, Verheij TJM. [Treatment of patients with herpes zoster by epidural injection of steroids and local anaesthetics: less pain after 1 month, but no effect on long-term postherpetic neuralgia--a randomised trial]. Ned Tijdschr Geneeskd 2006; 150:2649-55. [PMID: 17205943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
OBJECTIVE To assess the effectiveness of a single epidural injection of steroids and local anaesthetics, as a supplement to the standard treatment, for the prevention ofpostherpetic neuralgia in older patients with herpes zoster. DESIGN Open randomised trial. METHOD In the period September 2001-February 2004, 598 patients, aged > 50 years, with acute herpes zoster (rash for < 7 days) below dermatome C6, were randomly assigned to receive either standard therapy (oral antiviral agents and analgesics) alone or standard therapy plus an additional single epidural injection of 80 mg methylprednisolone and 10 mg bupivacaine. The primary endpoint was the proportion of patients with zoster-associated pain one month after inclusion. The presence and severity of zoster-associated pain at other time points were secondary endpoints. RESULTS At one month, pain was reported by 137 (48%) patients in the injection group versus 164 (58%) in the control group (relative risk; RR: 0.83; 95% CI: 0.71-0.97; p = 0.02). After three months, these values were 58 (21%) and 63 (24%), respectively (RR: 0.89; 95% CI: 0.65-1-21; p = 0.47), and at 6 months: 39 (15%) and 44 (17%) (RR: 0.85; 95% CI: 0.57-1-13; p = 0.43). No subgroups were detectable in which the relative risk for pain at one month after inclusion substantially differed from the overall estimate. At one month, the median severity of pain in the injection group was 2 (on a 100-points scale) versus 6 in the control group (p = 0.02). At later follow-up, there was no longer any statistically significant difference in the severity of pain between the two groups. No patient had major adverse events related to the epidural injection. CONCLUSION A single epidural injection of steroids and local anaesthetics in the acute phase of herpes zoster resulted in a modest decrease in zoster-associated pain in the first month. This treatment did not, however, prevent long-term postherpetic neuralgia.
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Affiliation(s)
- W Opstelten
- Julius Centrum voor Gezondheidswetenschappen en Eerstelijns Geneeskunde, Universitair Medisch Centrum Utrecht, Postbus 85.060, 3508 AB Utrecht.
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Geurts JW, van Wijk RM, Stolker RJ, Groen GJ. Efficacy of radiofrequency procedures for the treatment of spinal pain: a systematic review of randomized clinical trials. Reg Anesth Pain Med 2001; 26:394-400. [PMID: 11561257 DOI: 10.1053/rapm.2001.23673] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES The use of radiofrequency (RF) procedures in the peripheral nervous system to treat chronic spinal pain has been the subject of controversy. Publications concerned only uncontrolled studies, and irreversible nervous tissue damage was believed to be responsible for the effect, if any. In recent years, randomized, controlled studies have appeared, which have attested to an increasing use of these techniques. This is a systematic review of randomized controlled trials on RF procedures for spinal pain. METHODS We performed a standardized literature search for randomized, controlled trials. Three adjudicators independently registered trial methodology and outcome using validated and subject-related instruments. Interadjudicator disagreement was resolved by discussion. It was found necessary to devise additional parameters of study assessment. RESULTS Six trials met the inclusion criteria. This small number, along with clinical and technical heterogeneity precluded statistical analysis. All studies, whether high or low quality, reported positive outcomes. CONCLUSIONS We conclude that there is moderate evidence that RF lumbar facet denervation is more effective for chronic low back pain than placebo. Limited evidence exists for efficacy of RF neurotomy in chronic cervical zygapophyseal joint pain after flexion-extension injury. There is limited evidence that RF heating of the dorsal root ganglion is more effective than placebo in chronic cervicobrachialgia. We recommend the systematic application of our additional parameter assessments for future evaluations of RF studies. These additional parameters should also be used in the preparation of future trial protocols of RF procedures for the treatment of chronic pain.
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Affiliation(s)
- J W Geurts
- Department of Anesthesiology, Rijnstate Hospital, Arnhem, The Netherlands.
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Abstract
Forty-five patients, 12 men and 33 women with an age range of 17 to 88 years (median 52 years), were selected for a posterior thoracic percutaneous partial rhizotomy (PPR) based on the following criteria. Each patient had at least a 6-month history of irradiating pain that followed the segmental pattern of an intercostal nerve and had not responded to conservative treatment. In addition, no causal treatment was available and there was a temporary positive response to an intercostal blockade with lidocaine. In the lower thoracic region (T8-12) PPR was performed with the usual dorsolateral technique; in the upper thoracic region a dorsal approach was used by means of a drill hole made with a Kirschner wire in the vertebral arch. The 45 patients underwent 53 thoracic PPR operations. Patients were evaluated 2 months after treatment. Thirty patients (66.7%) were pain-free: in 11 cases (24.4%) more than 50% improvement was achieved, and in four (8.9%) there was no improvement. Side effects consisting of a transient burning pain or a mild transient sensory loss occurred in eight patients (17.7%). After a follow-up period of 13 to 46 months (median 24 months) results were evaluated in 41 patients; five patients had undergone reintervention. Excellent long-term results were achieved in 20 patients (48.8%), good results in 15 (36.6%), and poor results in six (14.6%). It is concluded, that when conservative treatment fails, thoracic PPR may prove an effective and safe treatment for chronic segmental thoracic pain.
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Affiliation(s)
- R J Stolker
- Pain Clinic, University Hospital, Utrecht, The Netherlands
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Stolker RJ, Vervest AC, Groen GJ. Parameters in electrode positioning in thoracic percutaneous facet denervation: an anatomical study. Acta Neurochir (Wien) 1994; 128:32-9. [PMID: 7847141 DOI: 10.1007/bf01400650] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The purpose of the present study was to verify if needle placement in thoracic percutaneous facet denervation (PFD), based on bony landmarks, and under fluoroscopic guidance, would lead to constant anatomical positioning; and hence to an adequate placement at the assumed target, i.e., the medial branch of the dorsal ramus of the spinal nerve; and furthermore to determine if interpretation of the needle position by CT is more reliable than by fluoroscopy. The procedures were carried out bilaterally at all 12 levels on two cadavers, simulating the clinical setting as much as possible. In 44 cases the position of the needles was determined on hard copies of fluoroscopic images, 1.5 mm interval CT-images, surface-photographs, and on counterstained 25 microns sections obtained by a multirange heavy duty cryomicrotome. The sections established that standardized use of bony landmarks under fluoroscopic control can result in reproducible anatomical needle positioning in thoracic PFD. Nervous tissue was hit in 27 (61%) cases, but the supposed target structure, i.e., the medial branch "stem" was never hit. In none of the procedures was an accidental pleural puncture observed. The correlation between fluoroscopic images and sections was poor. The correlation between CT and sections was better, except for the mediolateral direction. The results of the present study suggest that "pure" anatomical positioning based on bony landmarks analogous to those used in the lumbar region is not reliable enough for thoracic PFD, and that corrections after electrostimulation substantially contribute to obtaining an adequate position of the needle.
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Affiliation(s)
- R J Stolker
- Department of Functional Anatomy, Utrecht University, The Netherlands
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Stolker RJ, Sluijter ME, Rohof OJ. [Increased pain caused by pain treatment]. Ned Tijdschr Geneeskd 1993; 137:2108-9. [PMID: 7661887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Abstract
In 40 patients with chronic thoracic spinal pain of more than 12 months duration which failed to respond to conservative treatment and with a previous evaluation by specialists, mainly neurologists and orthopaedic surgeons, the diagnosis of facet syndrome was made. This diagnosis was based on clinical criteria and a transient positive response to a prognostic blockade of the medial branch of the dorsal ramus of the thoracic spinal nerve. They were selected to undergo percutaneous radiofrequency denervation of the facet joints. The short and long-term results of 51 percutaneous thoracic facet denervations in 40 patients are described. After 2 months, 19 patients (47.5%) were pain-free, 14 patients (35%) had more than 50% pain-relief, and 7 patients (17.5%) had no relief. After a follow-up of 18-54 (average 31) months in 36 cases (3 patients had died because of malignancy, and 1 had undergone a spinal fusion), 16 patients (44%) were pain-free, 14 patients (39%) had more than 50% pain-relief and in 6 cases (17%) the result was poor. Adverse effects consisted of postoperative pain in 5 patients (12.5%). When conservative treatment fails, percutaneous thoracic facet denervation can be a safe and beneficial therapy in chronic thoracic spinal pain originating from the facet joints.
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Affiliation(s)
- R J Stolker
- Pain Clinic University Hospital Utrecht, The Netherlands
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Stolker RJ. [Opioids and chronic benign pain]. Ned Tijdschr Geneeskd 1993; 137:310-1. [PMID: 8094542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Stolker RJ, Rohof O, Vervest A. Some considerations about the treatment of trigeminal neuralgia with intrathecal baclofen. Schmerz 1992; 6:153-4. [DOI: 10.1007/bf02528138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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