Tag: Soft Tissue Surgery

Historical data and recent studies show that standardised extended (D2) lymphadenectomy leads to better results than standardised limited (D1) lymphadenectomy. Based on these findings, the Dutch D1D2 trial, a nationwide prospectively randomised clinical trial, was undertaken to compare D2 with D1 lymphadenectomy in patients with resectable primary adenocarcinoma of the stomach. The aim of the study was to assess the effect of D2 compared with D1 surgery on disease recurrence and survival in patients treated with curative intent. Between August, 1989, and July, 1993, patients were entered and randomised at 80 participating hospitals by means of a telephone call to the central data centre of the trial. The sequence of randomisation was in blocks of six with stratification for the participating centre. Eligibility criteria were a histologically proven adenocarcinoma of the stomach without evidence of distance metastasis, age younger than 85 years, and adequate physical condition for D1 or D2 lymphadenectomy. Patients were excluded if they had previous or coexisting cancer or had undergone gastrectomy for benign tumours. Strict quality control measures for pathological assessment were implemented and monitored. Analyses were by intention to treat. This study is registered with the NCI trial register, as DUT-KWF-CKVO-8905, EU-90003.

A total of 1078 patients were entered in the study, of whom 996 were eligible. 711 patients underwent the randomly assigned treatment with curative intent (380 in the D1 group and 331 in the D2 group) and 285 had palliative treatment. Data were collected prospectively and all patients were followed up for a median time of 15•2 years (range 6•9—17•9 years). Analyses were done for the 711 patients treated with curative intent and were according to the allocated treatment group. Of the 711 patients, 174 (25%) were alive, all but one without recurrence. Overall 15-year survival was 21% (82 patients) for the D1 group and 29% (92 patients) for the D2 group (p=0•34). Gastric-cancer-related death rate was significantly higher in the D1 group (48%, 182 patients) compared with the D2 group (37%, 123 patients), whereas death due to other diseases was similar in both groups. Local recurrence was 22% (82 patients) in the D1 group versus 12% (40 patients) in D2, and regional recurrence was 19% (73 patients) in D1 versus 13% (43 patients) in D2. Patients who had the D2 procedure had a significantly higher operative mortality rate than those who had D1 (n=32 [10%] vs n=15 [4%]; 95% CI for the difference 2—9; p=0•004), higher complication rate (n=142 [43%] vs n=94 [25%]; 11—25; p<0•0001), and higher reoperation rate (n=59 [18%] vs n=30 [8%]; 5—15; p=0•00016). After a median follow-up of 15 years, D2 lymphadenectomy is associated with lower locoregional recurrence and gastric-cancer-related death rates than D1 surgery. The D2 procedure was also associated with significantly higher postoperative mortality, morbidity, and reoperation rates. Because a safer, spleen-preserving D2 resection technique is currently available in high-volume centres, D2 lymphadenectomy is the recommended surgical approach for patients with resectable (curable) gastric cancer. The Lancet
May 25, 2010

Original web page at The Lancet

Surgical site infection (SSI) is an adverse event in which a close relation between process of care and outcome has been demonstrated: administration of antibiotic prophylaxis decreases the risk of SSI. In our tertiary referral centre, a SURgical PAtient Safety System (SURPASS) checklist was developed and implemented. This multidisciplinary checklist covers the entire surgical pathway and includes, among other items, administration of antibiotic prophylaxis before induction of anaesthesia. The aim of this study was to determine the effect of SURPASS implementation on timing of antibiotic prophylaxis. A retrospective analysis was performed on two cohorts of patients: one cohort of surgical patients that underwent surgery before implementation of the checklist and a comparable cohort after implementation. The interval between administration of antibiotic prophylaxis and incision was compared between the two cohorts.

A total of 772 surgical procedures were included. More than half of procedures were gastro-intestinal; others were vascular, trauma and hernia repair procedures. After implementation, the checklist was used in 81.4% of procedures. The interval between administration of antibiotic prophylaxis and incision increased from 23.9 minutes before implementation of SURPASS to 29.9 minutes after implementation (p=0.047). In procedures where the checklist was used, the interval increased to 32.9 minutes (p=0.004). The proportion of patients that did not receive antibiotics until after the incision decreased significantly. The use of the SURPASS checklist leads to better compliance with regard to the timing of antibiotic prophylaxis administration.

BioMed Central
April 27, 2010

Original web page at Patient Safety in Surgery

If you’ve been waiting for the day to arrive when computers actually start performing surgery, that moment might soon be upon us. A French team has developed a computerized 3D model that allows surgeons to use robotics to operate on a beating heart, according to a report in The International Journal of Robotics Research, published by SAGE. The robotic technology predicts the movement of the heart as it beats, enabling the surgical tools to move in concert with each beat. It means that the surgeon can perform a procedure as if the heart was stationary. This development could be very important for millions of patients who require less invasive surgical heart procedures, where stopping the heart from beating would cause unnecessary risk. Rogério Richa, Philippe Poignet and Chao Liu from France’s Montpellier Laboratory of Informatics, Robotics, and Microelectronics developed a three-dimensional computerized model that tracks the motion of the heart’s surface as it beats. In addition to the heart, this model also accounts for the movement of a patient’s chest wall during breathing. Known as the “thin-plate spline deformable model”, this new computerized approach allows the robotic arm to continually adjust to heart and chest movements during surgery.

The new approach relies on a mathematical representation of the heart’s surface as it moves in three dimensions during pumping. Researchers have made many attempts to use computer modelling to account for heart and breathing motion. However, previous efforts have relied on 2D imaging combined with other steps, making them too slow to provide instantaneous feedback during an operation. This new 3D imaging predicts the heart movements in a single step, making it faster in real-life surgical environments. Over the last 10 years, robotic arms have become essential in many kinds of surgical procedures, including microsurgery and operations that require extremely delicate movements. However, these machines also prevent the surgeons from using their sense of touch and coordination to adjust for rapidly changing environments. This new computer-generated model makes it possible for the surgeon to focus on suturing or cutting without having to adjust for the moving surface. Ultimately, this breakthrough will have many potential applications including heart surgery, coronary bypasses, and many kinds of brain surgery.

This is the first successful attempt to effectively isolate the physical movements of the heart and lungs during surgery. This has been particularly difficult given the heart’s irregular shape, as well as its tendency to expand outward in all directions during beating. The heart’s irregular surface also makes it more difficult to use visual tracking to accurately pinpoint movement. This important development will allow surgeons to perform less invasive procedures that are not “life-or-death”, but that do require a high level of precision and can have life-altering consequences for patients worldwide. To date, patients have gone without many of these procedures because the risk of complications during surgery outweighed the benefits.

EurekAlert! Medicine
January 12, 2010

Original web page at EurekAlert! Medicine

A novel technology involving use of stem cells, developed by Hebrew University of Jerusalem researchers, has been applied to provide better and rapid healing for patients suffering from complicated bone fractures. The technology, involving isolation of the stem cells from bone marrow, was developed by Dr. Zulma Gazit, Dr. Gadi Pelled, Prof. Dan Gazit and their research team at the Skeletal Biotechnology Laboratory at the Hebrew University Faculty of Dental Medicine and was given public exposure in an article that appeared in the journal Stem Cells. The technology has now successfully been used to treat complicated fractures in seven patients at the Hadassah University Hospital in Ein Kerem, Jerusalem. To date, in clinical orthopedics, standard treatment for severe bone loss has involved either amputation or a prolonged period of disability. The use of prosthetic implants tends to fail in the long term. Excessive bone loss may result in non-uniting fractures, which are observed in more than one million new cases per year in the US alone. In recent years, the use of mesenchymal stem cells (MSCs, or multipotent stem cells that can differentiate into a variety of cell types) has been claimed to be a promising biological therapy that could be used to treat complicated fractures and other disorders in the skeleton. These cells constitute a unique population of adult stem cells that can readily be isolated from various sites in the human body, especially from bone marrow and adipose (fat) tissues. Following isolation, MSCs can be utilized to repair a variety of injured tissues including bone, cartilage, tendon, intervertebral discs and even the heart muscle.

The conventional method of MSC isolation, using prolonged periods of growth in designated incubators, has proved to be laborious, costly and also possibly injurious to the therapeutic quality of the cells. Therefore, an alternative method involving the immediate use of these stem cells was an unmet need in the field of regenerative medicine. Now, the Hebrew University group has developed a technology called immuno-isolation in which MSCs are sorted out from the other cells residing in a bone marrow sample, using a specific antibody. In the Stem Cell paper it was shown that the immuno-isolated cells could be immediately used to form new bone tissue when implanted in laboratory animals, without having to undergo a prolonged incubator growth period. Following this breakthrough, a unique and close collaboration was established among clinicians (Prof. Meir Liebergall, head of orthopedics, Hadassah University Hospital), the Good Manufacturing Practice (GMP) facility at Hadassah (Headed by Prof. Eithan Galun) and the Gazit group at the Faculty of Dental Medicine.

Within this collaborative effort, a clinical-grade protocol for the use of immuno-isolated MSCs was established. Subsequently a clinical trial was initiated at Hadassah, aimed at establishing the foundation for the use of immuno-isolated MSCs in orthopedic surgery. To date, seven patients suffering from complicated fractures have been treated successfully with a combination of their own immuno-isolated MSCs and blood products. The entire procedure lasted a few hours and without any need to grow the cells for weeks in a laboratory. It is anticipated that future development of the current endeavor will extend to treat other injuries in the skeleton, such as degenerated intervertebral discs or torn tendons. The Gazit group believes that further clinical trials will demonstrate that the immuno-isolation technology is useful in overcoming morbidity in patients suffering from skeletal fractures and diseases, and might restore function and quality of life to sick and injured people.

Science Daily
December 15, 2009

Original web page at Science Daily

An innovative method is being used to repair the breastbone after it is intentionally broken to provide access to the heart during open-heart surgery. The technique uses a state-of-the-art adhesive that rapidly bonds to bone and accelerates the recovery process. “We can now heal the breastbone in hours instead of weeks after open-heart surgery. Patients can make a full recovery after surgery and get back to full physical activities in days instead of months,” reports Dr. Paul W.M. Fedak, MD PhD FRCSC, a cardiac surgeon at Foothills Medical Centre and scientist at the Faculty of Medicine who pioneered the new procedure. Over 20 patients have received the new technique in Calgary as part of a pilot study. Fedak and Kathryn King, RN PhD are the co-principal investigators on the study. King, a cardiovascular nurse scientist, is an expert in post-operative recovery after open-heart surgery. “We know that recovery from sternotomy is a multi-faceted process that includes not only healing of the breastbone but the ability to return to normal activities,” she says. “Being able to resume normal activities is a hallmark of a good recovery; this surgical innovation should enable that.”

The patients report substantially less pain and discomfort after surgery and the use of strong pain medication, such as narcotics, is profoundly reduced if not completely eliminated with use of the procedure. The ability to deep breathe, known to play a key role in recovery, is also substantially improved. Richard Cuming’s chest was repaired in June KryptoniteTM adhesive, a biocompatible polymer (manufactured by Doctors Research Group Inc., (Connecticut USA). Two years earlier he had open-heart surgery repaired the traditional way — sewing his breastbone back together with wire. That wire broke, his breastbone opened, and Cuming had a difficult time. “I couldn’t accomplish simple tasks like squeezing toothpaste, turning the steering wheel in my car or pulling open a heavy door without discomfort and pain. Anytime I coughed or sneezed there was movement in my chest and significant pain, I think the worst part of the ordeal was that I stopped doing things ‘in case they would hurt'” says Cuming. After his chest was ‘glued’ back together using KryptoniteTM adhesive and wires he had an entirely different experience. “I had a little bit of pain, but this was a walk in the park compared to my earlier recovery. I can do anything I could do prior to the original surgery. I feel wonderful.”

Science Daily
December 1, 2009

Original web page at Science Daily

Mayo Clinic surgical researchers are reporting a 93 percent success rate in recent animal tests of endoscopic repair of perforated ulcers. The goal is to advance the use of an endoscope — which allows access to organs through natural openings, such as the mouth — for a less invasive alternative to laparoscopic techniques (surgery performed through a small incision) or conventional surgery. They will present their findings from recent animal studies today at the American College of Surgeons 95th Clinical Congress in Chicago. “Laparoscopic surgery for this condition is only 80 percent successful for a variety of reasons,” says Juliane Bingener, M.D., senior author on the study. “In our laboratory experiments we were over 90% successful. We also hope to ultimately reduce the risk to the patient overall and reduce postoperative complications.” The process is called natural orifice translumenal endoscopic surgery (NOTES). The goal is to ultimately limit the physiological impact on the patient. While endoscopic repair limits the level of anesthesia used, in the distant future, it may be done without anesthesia, thus limiting one possible procedural side effect. “Laparoscopy is great, but not all surgeons do it. It’s not easy to do. It’s technically advanced,” says Erica Moran, M.D., Mayo surgeon and researcher. “But it’s already been shown that there are many benefits if we can do noninvasive procedures with people who are actually quite ill.” The researchers are seeking regulatory approval to begin a human clinical trial using the technique in the near future. The doctors emphasize that the endoscopic approach may not be appropriate for all cases. Each patient’s background symptoms and other medical conditions would need to be considered in determining which approach to use.

Mayo Clinic
November 3, 2009

Original web page at Mayo Clinic

More than six million people in the U.S. suffer from persistent wounds — open sores that never seem to heal or, once apparently healed, return with a vengeance. The bedridden elderly and infirm are prone to painful and dangerous pressure ulcers, and diabetics are susceptible to wounds caused by a lack of blood flow to the extremities. The problem is chronic,” says Prof. Amihay Freeman of TAU’s Department of Molecular Microbiology and Biotechnology. To solve it, he’s developed a unique device that uses a solution to whisk away dead tissue, bathing the wound while keeping dangerous bacteria away. Prof. Freeman’s “Dermastream” provides an enzyme-based solution that flows continuously over the wound, offering an alternative treatment to combat a problem for which current treatments are costly and labor-intensive. It could save the American healthcare system millions of dollars a year, and could be in hospitals and doctor’s offices soon: Dermastream has passed clinical trials in Israeli hospitals and may be available in the U.S. within the next year, says Prof. Freeman.

Employing a special solution developed at Prof. Freeman’s TAU laboratory, Dermastream offers a new approach to chronic wound care, a specialty known as “continuous streaming therapy.” “Our basic idea is simple,” says Prof. Freeman. “We treat the wound by streaming a solution in a continuous manner. Traditional methods require wound scraping to remove necrotic tissue. That is expensive, painful and extremely uncomfortable to the patient. And while active ingredients applied with bandages on a wound may work for a couple of hours, after that the wound fights back. The bacteria build up again, creating a tedious and long battle.” Dermastream “flows” under a plastic cover that seals the wound, providing negative pressure that promotes faster healing. The active biological ingredient, delivered in a hypertonic medium, works to heal hard-to-shake chronic wounds. While traditional bandaging methods may take months to become fully effective, Dermastream can heal chronic wounds in weeks, Prof. Freeman says.

Dermastream is intended for use in hospitals, nursing homes, outpatient clinics and homecare. Prof. Freeman has founded a company that is currently collaborating with a Veterans Association hospital in Tucson, AZ, to bring the technology to the U.S. market. Dermastream was an outgrowth of Prof. Freeman’s original laboratory research, which investigated the use of enzymes for pharmaceutical applications. Enzymes were previously applied to wounds as ointments, but were slow-acting and required a great deal of time to apply. Coupling the enzymes with a continuous stream of liquid, he unlocked the power of the enzymes in a way that works and makes sense, he says. “My solution helps doctors regain control of the chronic wound, making management more efficient, and vastly improving the quality of their patients’ lives,” Prof. Freeman concludes.

Science Daily
September 22, 2009

Original web page at Science Daily

Limb-sparing surgery, which has been taking the place of amputation for bone and soft tissue sarcomas of the lower limb in recent years, may not provide much or even any additional benefit to patients according to a new review. The analysis, published in the September 15, 2009 issue of Cancer, a peer-reviewed journal of the American Cancer Society, indicates that patients and physicians should rethink the pros and cons of limb-sparing surgery and amputation. Patients with tumors of the bone or soft tissue in their arms and legs require surgery to remove their cancer. To compare the costs and benefits of amputation compared with limb-sparing surgery in these patients, Canadian researchers Ronald Barr, M.D., M.B., Ch.B., of McMaster University and Jay Wunder, M.D., M.Sc., of the Mount Sinai Hospital and the University of Toronto reviewed all published papers on limb-sparing surgery that also measured patients’ functional health and quality of life.

The review found that while limb-sparing surgery is generally as effective as amputation in ridding the patient of cancer, it tends to be associated with more early and late complications. Surprisingly, studies also show that, particularly for patients with lower limb bone sarcomas, limb salvage does not provide a better quality of life to patients than amputation. Most studies have found that the differences in disability between amputation and limb-sparing patients are smaller than expected. Many revealed no significant differences in psychological health and quality of life between patients who underwent amputations and those who had limb-sparing surgery. However, there appear to be greater advantages to limb-sparing surgery over amputation for higher surgical sites in the lower limb, such as the hip. Some studies have looked at the costs of amputation vs limb-sparing surgery. “Up front” surgical costs, the duration of rehabilitation, and the need for revisions are all greater for limb-sparing surgery. However, amputation carries longer term costs related to artificial limb manufacture, maintenance, and replacement. The authors say additional research is needed to provide a thorough comparison of amputation and limb-sparing surgery in different types of patients with bone and soft tissue sarcomas. “Future studies that include function, health-related quality of life, economics, and stratification of patients by age will be useful contributions to decision-making… by patients, health care providers and administrators,” said Dr. Wunder.

Science Daily
August 25, 2009

Original web page at Science Daily

Researchers from Boston University School of Medicine (BUSM) have shown that endoscopic surgery is a valid treatment option for treating esthesioneuroblastoma (cancer of the nasal cavity), in addition to traditional open surgery and nonsurgical treatments. Esthesioneuroblastoma is a very rare cancer that develops in the upper part of the nasal cavity and thought to derive from neural tissue associated with the sense of smell. While this tumor generally grows slowly, in some cases it progresses rapidly and aggressively. The faster growing tumors are capable of widespread metastasis. According to the BUSM researchers, the complex nature of this tumor has led to much debate regarding the optimal treatment modality. Several previous studies have analyzed survival rates of various treatments, the majority of which have shown that the most effective strategy is a combination of surgery and radiotherapy with or without chemotherapy. However, the evolution of surgical techniques has created another surgical option in the form of endoscopic surgery.

This study examined recent literature regarding outcomes of esthesioneuroblastoma treatment between 1992 and 2008 and found overall, surgery yielded more disease-free outcomes and better survival rates than nonsurgical treatment modalities. Endoscopic surgery produced better survival rates than open surgery. In addition, there was no significant difference between follow-up times in the endoscopic and open surgery groups. “We did find a statistically significant difference between the study publication years of the open and endoscopic surgery groups because the open surgery literature considerably predated endoscopic treatment. To account for this discrepancy, we grouped the data according to publication year and performed further analysis and found the endoscopic surgery group maintained better survival rates than the open surgery group,” said lead author Anand K. Devaiah, MD, FACS, an assistant professor in the departments of otolaryngology – head and neck surgery and neurological surgery as well as an attending in the department of otolaryngology at Boston Medical Center. He and his co-author, BUSM III student Michael Andreoli, presented their work at the Triological Society Eastern Section Meeting, which was met with great enthusiasm. “Although this meta-analysis suggests that the efficacy of endoscopic and endoscopic- assisted surgery is comparable to open surgery for less invasive tumors, further prospective studies are required to establish more definite conclusions, especially for larger tumors,” added Devaiah. “It helps validate this revolutionary method of surgery that we perform here at BMC, one of the few centers in the world that can offer patients endoscopic skull base surgery for these and other skull base tumors.”

Science Daily
August 11, 2009

Original web page at Science Daily

Johns Hopkins biomedical engineering students have demonstrated a practical way to embed a patient’s own adult stem cells in the surgical thread that doctors use to repair serious orthopedic injuries such as ruptured tendons. The goal, the students said, is to enhance healing and reduce the likelihood of re-injury without changing the surgical procedure itself. The project team — 10 undergraduates sponsored by Bioactive Surgical Inc., a Maryland medical technology company — won first place in the recent Design Day 2009 competition conducted by the university’s Department of Biomedical Engineering. In collaboration with orthopedic physicians, the students have begun testing the stem cell–bearing sutures in an animal model, paving the way for possible human trials within about five years. The students believe this technology has great promise for the treatment of debilitating tendon, ligament and muscle injuries, often sports-related, that affect thousands of young and middle-aged adults annually. “Using sutures that carry stems cells to the injury site would not change the way surgeons repair the injury,” said Matt Rubashkin, the student team leader, “but we believe the stem cells will significantly speed up and improve the healing process. And because the stem cells will come from the patient, there should be no rejection problems.”

The corporate sponsor, Bioactive Surgical, developed the patent-pending concept for a new way to embed stem cells in sutures during the surgical process. The company then enlisted the student team to assemble and test a prototype to demonstrate that the concept was sound. The undergraduates performed this work during the yearlong Design Team course, required by the school’s Biomedical Engineering Department. The undergraduate team located a machine that could weave surgical thread in a way that would ensure the most effective delivery and long-term survival of the stem cells. The team conducted some aspects of the animal testing, although orthopedic physicians performed the surgical procedures. The students also prepared grant applications, seeking funding for additional testing of the technology, in collaboration with Bioactive Surgical. “The students did a phenomenal job,” said Richard H. Spedden, chief executive officer of Bioactive Surgical. As envisioned by the company and the students, a doctor would withdraw bone marrow containing stem cells from a patient’s hip while the patient was under anesthesia. The stem cells would then be embedded in the novel suture through a quick and easily performed proprietary process. The surgeon would then stitch together the ruptured Achilles tendon or other injury in the conventional manner but using the sutures embedded with stem cells.

At the site of the injury, the stem cells are expected to reduce inflammation and release growth factor proteins that speed up the healing, enhancing the prospects for a full recovery and reducing the likelihood of re-injury. The team’s preliminary experiments in an animal model have yielded promising results, indicating that the stem cells attached to the sutures can survive the surgical process and retain the ability to turn into replacement tissue, such as tendon or cartilage. If similar results occur in future human testing, many patients may benefit. Researching the business opportunity, the students found that about 46,000 people in the United States undergo Achilles tendon repair surgery every year, with a mean age between 30 and 50 years old. The operation and subsequent therapy costs are about $40,000 per case, the students said. “After surgery, the recovery process can take up to a year. In about 20 percent of the cases, the surgery fails, and another operation is needed,” said Rubashkin, a Barrington, Ill., resident who will begin his senior year at Johns Hopkins in the fall. “Anything we can do to speed up the healing and lower the failure rate and the additional medical costs could make a big difference.”

Lew Schon, a leading Baltimore foot and ankle surgeon and one of the inventors of the technology, said, “These students have demonstrated an amazing amount of initiative and leadership in all aspects of this project, including actually producing the suture and designing the ensuing mechanical, cell-based and animal trials.” Schon, who also is an assistant professor of orthopedic surgery in the Johns Hopkins School of Medicine, added that “the students exceeded all expectations. They have probably cut at least a year off of the development time of this technology, and they are definitely advancing the science in this emerging area.” The biomedical engineering students say some of their grant applications are aimed at studying the use of stem cell–bearing sutures for other orthopedic applications, such as rotator cuff repairs. Future uses in cardiology and obstetrics are also being considered.

Science Daily
August 11, 2009

Original web page at Science Daily

Surgical gloves that develop holes or leaks during a procedure appear to increase the risk of infection at the surgical site among patients who are not given antibiotics beforehand, according to a new article. Despite substantial efforts to maintain sterile conditions during surgery, pathogens can still be transmitted through contact with skin or blood, according to background information in the article. To prevent skin-borne pathogens on the hands from being transferred to patients, surgical staff wear sterile gloves as a protective barrier. When gloves are perforated by needle puncture, spiked bone fragments, sharp surfaces on surgical instruments or another cause, the barrier breaks down and bacteria can be transferred. The frequency of glove perforation increases in surgical procedures lasting more than two hours and has been found to range from 8 percent to 50 percent.

Heidi Misteli, M.D., of University Hospital Basel, Basel, Switzerland, and colleagues studied a series of 4,417 surgical procedures performed at the facility between 2000 and 2001. Of these, 677 involved glove perforations, whereas surgical gloves remained intact during 3,470 procedures. Antimicrobial prophylaxis, (antibiotic therapy given before surgery to prevent infection) was used in 3,233 of the surgeries, including 605 in which perforated gloves were detected. A total of 188 instances of surgical site infection (4.5 percent) were identified, including 51 (7.5 percent) in procedures performed with perforated gloves and 137 (3.9 percent) in procedures where gloves remained intact. In procedures involving antimicrobial prophylaxis, glove perforation was not associated with surgical site infection after other, related factors were considered. “In the absence of surgical antimicrobial prophylaxis, glove leakage was associated with a surgical site infection rate of 12.7 percent, as opposed to 2.9 percent when asepsis was not breached,” the authors write. “This difference proved to be statistically significant when assessed with both univariate and multivariate analyses.”

Measures to decrease the risk of glove perforation—including double gloving and replacing gloves after a specified period of time—are effective and safe and should be encouraged, although implementing them in clinical practice is sometimes difficult, the authors note. “Although surgical antimicrobial prophylaxis has been demonstrated to prevent surgical site infection after clean surgery in several randomized controlled trials, there is no current consensus regarding its use in this area,” they conclude. “The present results support an extended indication of surgical antimicrobial prophylaxis to all clean procedures in the absence of strict precautions taken to prevent glove perforation. The advantages of this surgical site infection prevention strategy, however, must be balanced against the costs and adverse effects of the prophylactic antimicrobials, such as drug reactions or increased bacterial resistance.”

Science Daily
July 14, 2009

Original web page at Science Daily

A new study published by the American Society of Plastic Surgeons reveals that one of the most common conditions caused by Rheumatoid Arthritis (RA) is best treated surgically, sooner rather than later. Patients with RA frequently experience a debilitating condition known as metacarpophalangeal joint disease, which is usually treated by replacing the knuckle joints with solid silicone joints. However, this treatment (and others like it) has spurred great disagreement between hand surgeons and rheumatologists regarding the indications, timing and perceived outcomes of the procedure; rheumatologists tend to refer late-stage patients for surgery whereas hand surgeons believe that earlier intervention can yield more positive outcomes.

In the largest cohort study of its kind, researchers from Michigan, Maryland, and the United Kingdom evaluated the surgical outcomes of 70 RA patients who suffered from varying degrees of hand deformities. Following reconstruction, patients were separated into two groups based on the degree of deformity, and the outcomes of the reconstruction were assessed at 6 months and at years 1, 2 and 3. After reconstruction, both groups had positive self-reported hand outcomes and showed statistically significant improvement from baseline. However, researchers found that the more severe group still had significant deformities – showing that the more serious the malformation, the more difficult it is to correct.

This study acknowledges that the management of rheumatoid hand and wrist problems is challenging because of the lack of evidenced-based research regarding the management of these difficult patients. Findings from this study support the general view of hand surgeons that surgery is beneficial to both the early stage and late stage patients. Both specialties agree that working together in a team approach will enhance the quality of life for the RA population. This study appears in the June issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons (ASPS). According to the Arthritis Foundation, nearly 1.3 million Americans suffer from RA. In 2008, more than 8,000 hand surgeries were performed due to complications from Arthritis, according to ASPS statistics.

Science Daily
June 30, 2009

Original web page at Science Daily

Trigeminal neuralgia is characterized by episodes of intense, stabbing, electric-shock-like pain in areas of the face which have branches of the trigeminal nerve (lips, eyes, nose, scalp, forehead, upper jaw and lower jaw). The trigeminal nerve carries sensation from the face to the brain. In trigeminal neuralgia, the nerve function is disrupted. Approximately 15,000 new patients are diagnosed with trigeminal neuralgia each year in the U.S. “Medical therapy eliminates or significantly reduces the pain for 75 percent of patients with trigeminal neuralgia, but the effectiveness generally decreases over time and surgery becomes necessary for patients to maintain their quality of life,” says Bruce Pollock, M.D., a neurosurgeon at Mayo Clinic and the lead author of this study. “In posterior fossa exploration surgery, the hope is to find a blood vessel pushing onto the trigeminal nerve that can be moved or displaced. We consider this to be the gold standard of trigeminal neuralgia surgeries. Stereotactic radiosurgery, on the other hand, directs radiation onto the nerve with the hope of creating a mild degree of damage to relieve patients of facial pain.”

Dr. Pollock and his team reviewed the records of 149 patients who had posterior fossa exploration surgery or stereotactic radiosurgery for trigeminal neuralgia between June 2001 and September 2007. Prior to surgery, patients were informed that posterior fossa exploration surgery was most likely to relieve facial pain without causing numbness. Sixty-one percent of patients chose to undergo posterior fossa exploration, while 39 percent opted for stereotactic radiosurgery. The researchers found that patients who had posterior fossa exploration were more than two times more likely to achieve and maintain pain relief without the need for medications. Additionally, posterior fossa exploration surgery was found to be safe, and the incidence of facial numbness was much lower after posterior fossa exploration surgery than after stereotactic radiosurgery. “Over the past 10 years, patient preference has emerged as an important deciding factor for surgical intervention, and a large number of patients choose stereotactic radiosurgery since it is less invasive,” says Dr. Pollock. “However, this study shows that the results with posterior fossa exploration surgery are far better. Therefore, we typically recommend posterior fossa exploration as the first line of management for patients requiring surgical treatment for trigeminal neuralgia.”

Mayo Clinic
May 19, 2009

Original web page at Mayo Clinic

When 91-year-old Irvin Lafferty was diagnosed with severe blockage of his heart valve—hardening that is formally known as aortic valve stenosis—open-heart surgery was out of the question. He’d already survived quadruple bypass while in his 50s, and having lived almost a century, Lafferty wasn’t a good candidate for heart surgery for many reasons. His local cardiologist referred him to surgical and interventional specialists at Chicago’s Bluhm Cardiovascular Institute of Northwestern Memorial Hospital. And, on January 21, 2009, Lafferty became the first patient in Illinois to receive a prosthetic heart valve through a procedure known as transapical transcatheter aortic valve implantation, which combines catheterization technology and traditional surgery, allowing doctors to implant a new heart valve in place of Lafferty’s diseased valve while his heart remained beating. “Traditional open-heart surgery is a very safe and effective way to replace diseased heart valves, but for many patients bypass surgery is not a viable option” says Patrick M. McCarthy, MD, Northwestern Memorial’s chief of cardiothoracic surgery and co-director of its Bluhm Institute and a Heller-Sacks professor of surgery at Northwestern University’s Feinberg School of Medicine. “By utilizing the percutaneous technique—meaning surgery is not required—we are able to greatly reduce risk for these patients. We see percutaneous valve repair as not only having a great impact upon how high-risk patients are treated, but in how heart valve disease is treated period, in the U.S. and around the world.”

McCarthy is a co-principal investigator for the clinical trial that provided Lafferty’s new heart valve, which is formally referred to as the Placement of AoRtic TraNscathetER Valve, or PARTNER. The Bluhm Institute is among the trial’s pioneering sites. McCarthy says the procedure builds upon a routine catheter-based procedure, the balloon aortic valvuloplasty. “Balloon aortic valvuloplasty has been traditionally offered as a palliative therapy for patients who were not candidates for aortic valve surgery,” said the hospital’s Director of the Cardiac Catheterization Laboratory Charles J. Davidson, MD, who is also a co-principal investigator for the trial and a professor of medicine at Northwestern University’s Feinberg School of Medicine. “This particular technique is a more durable treatment than balloon valvuloplasty and is potentially a breakthrough for treating high-risk patients.” Medical experts estimate every year nearly 200,000 people in the U.S. need new heart valves. Yet over half of them do not receive them primarily due to frailty, one of the most common reasons for exclusion from traditional open-heart surgery.

“Surgery becomes far too risky when patients are conditionally weak or frail,” says Chris Malaisrie MD, a Northwestern Memorial cardiac surgeon and member of the site team evaluating this new procedure. “The goal is to replace diseased valve at minimal risk to these patients—many of whom have very limited therapeutic options. Aortic valve replacement is one of few therapies offering both symptomatic relief and improved long-term survival.” During insertion, the artificial valve remains collapsed until it reaches its destination. It is then expanded and released in place of diseased aortic heart valves. The prosthesis is made of stainless steel and biological leaflets that help direct the flow of blood in the heart. It is permanent and integrates an expandable stent that holds the valve in its intended position. Northwestern Memorial utilizes both the transfemoral (through the groin) and transapical (through the ribs) approaches. Implantation occurs in a hybrid operating room suite that incorporates elements of both a traditional OR and catheterization laboratory.

Science Daily
April 7, 2009

Original web page at Science Daily

Pre-operative screening of patients for methicillin-resistant staphylococcus aureus (MRSA) may be an effective way to reduce infection rates following otolaryngic surgeries, according to new research published in the January 2009 issue of Otolaryngology – Head and Neck Surgery. The study, conducted by researchers at the Massachusetts Ear & Eye Infirmary, is the first to review otolaryngic procedures, and reviewed the medical records of 420 patients. Of the 241 non-pre-screened patients during a one-year period, nine patients had staphylococcus aureus infections, including two post-operative MRSA surgical site infections. Of the 179 patients pre-screened using a nasal swab, 24 patients were identified as having staphylococcus aureus colonies, and underwent pre-operative treatment; none of these patient cases resulted in post-operative MRSA infections.

MRSA, which was discovered in 1961, has emerged as an increasingly fatal infection in patients, as the superbug is resistant to most forms of penicillin and cephalosporins. MRSA commonly colonizes in the nostrils, can cause life-threatening pneumonias, can necrotize skin and wound infections, and is a particular risk to children, the elderly, and people with weak immune systems. Due to particular concerns about MRSA infections in otolaryngic surgeries, the authors recommend further, larger studies, with an emphasis on high-risk patients, including those with multiple comorbidities, head and neck cancer patients, patients receiving implanted devices, and patients with prior hospitalizations or multiple courses of antibiotics.

EurekAlert! Medicine
January 13, 2009

Original web page at EurekAlert! Medicine

One of the primary ways of treating brain cancer is surgically removing the tumors. The risk of this sort of procedure is obvious — it involves cutting away tissue from the brain, potentially severing nerve fibers and causing neurological damage. MRI and CT scans can reveal the extent of tumors, but only prior to surgery. These techniques rely on large instruments that cannot be used in the operating room, and during the operation the brain may relax and move, forcing surgeons to adjust where they are cutting to minimize the damage to the brain tissue. During surgery, doctors make these adjustments by asking their patients to perform certain tasks while electrically stimulating parts of the brain bordering where they plan to cut. The electrical stimulation inhibits brain function in that region, revealing whether losing that tissue would cause permanent damage. Although slow, this is a good way to detect and protect critical areas of the brain.

Now Paul Hoy and his colleagues at the University of Southampton in England are developing a rapid and highly sensitive method for measuring brain function across the entire area during surgery. The method is based on observing blood flow in the brain. Active brain regions have increased blood flow, and this change can be observed by looking at light reflected off the brain because hemoglobin, the protein that ferries oxygen within the bloodstream, will absorb light differently depending on whether it carries oxygen or not. Recently Hoy and his colleagues measured this signal on four people undergoing brain surgery and showed that their results agreed with the electrical stimulation. They hope that the technique will one day provide information quickly for neurosurgeons, and they are now collecting data that will lead to a clinical trial designed to test how effective the technique is.

Science Daily
October 28, 2008

Original web page at Science Daily

A study of almost 1,500 kidney cancer patients treated at Memorial Sloan Kettering Cancer Center suggests that surgery to spare as much kidney tissue as possible may improve overall survival in patients who also have reduced kidney function at the time their cancer is diagnosed. The finding is significant because both kidney cancer and decreased kidney function appear to be increasing. In patients who have the combination of kidney cancer and lowered kidney function, doctors should consider tissue-sparing surgery – versus complete removal – whenever it is technically feasible,” said Joseph Pettus, M.D., lead author and now an assistant professor of urology at Wake Forest University School of Medicine. “Currently this option is significantly underused.” Reporting in the Mayo Clinic Proceedings, a peer-reviewed medical journal, researchers found that among patients having surgery for kidney cancer, those who also had severely impaired kidney function were almost three times more likely to die than patients with normal kidney function.

Impaired kidney function can sometimes be related to the cancer itself. But impaired function can also be caused or compounded by a variety of other factors, including diabetes, hypertension and vascular disease. Impaired kidney function itself – even without a diagnosis of cancer – is related to increased risk of death and hospitalization. Surgery to remove a malignant tumor can further impair kidney function because the loss of kidney tissue affects kidney function over time. Researchers at Memorial Sloan Kettering had previously found that patients whose kidneys were completely removed were almost 12 times more likely to develop significantly impaired function in the remaining kidney than patients whose organs were partially removed. The study involved an analysis of data from kidney cancer patients treated during a 10-year period. Pettus conducted the research with colleagues at Sloan Kettering before moving to Wake Forest.

The research was based on the hypothesis that kidney cancer patients with reduced kidney function prior to surgery would have lower survival rates than cancer patients with normal kidney function. The researchers excluded patients whose disease had spread to the lymph nodes or other parts of the body. They found that median beginning levels of kidney function in all patients decreased during the 10-year period by about 10 percent. Compared to those with normal kidney function, patients who began with moderately reduced function were 150 percent more likely to die from any cause. Those with severely reduced function were almost three times (280 percent) more likely to die. Pettus said the findings suggest that obesity and related diseases that affect kidney function may be contributing to the rising death rates from kidney cancer. Overall death rates increased 323 percent among kidney cancer patients between 1983 and 2002 – despite the fact that the disease is being detected earlier. He said that rising rates of kidney cancer – combined with a decline in kidney function – is almost a “perfect storm” scenario which may explain the decrease in survival, even among patients with early stages of kidney cancer.

“These findings underscore the importance of considering baseline kidney function when devising treatment plans for patients with kidney tumors,” said Pettus. He said the findings raise concerns that surgery may result in more medical harm than benefit to treating the cancer. “Our data beg the question of whether patients with moderate to severe kidney disease and small tumors might be better managed through tissue-sparing techniques or a ‘watchful waiting’ approach,” said Pettus. “Completely removing the kidney may result in more harm than good, particularly in elderly patients with small tumors and other medical problems. For these patients, careful surveillance may be a legitimate option with surgery reserved for cases where the tumor increases in size.” Research has shown that for tumors that are 7 cm or less, partial removal of the kidney provides equal cancer control to total removal. However, partial removal accounted for only 7.5 percent of kidney surgeries between 1988 and 2002. And for smaller tumors, only 20 percent were treated with partial removal of the kidney.

Science Daily
October 14, 2008

Original web page at Science Daily

In April of last year, surgeons at NewYork-Presbyterian Hospital/Columbia University Medical Center made headlines by removing a women’s gallbladder through her uterus using a flexible endoscope, aided by several external incisions for added visibility. Now, they have performed the same procedure without a single external incision in what surgeons report may be the first surgery of its kind in the United States. Led by Dr. Marc Bessler the procedure is offered as part of an ongoing clinical research trial and could prove to have advantages over traditional endoscopic surgery, including reduced pain, quicker recovery time and absence of visible scarring. Employing this technique, called NOTES (natural-orifice translumenal endoscopic surgery), the endoscope was inserted through a one-inch incision behind the uterus and into her body cavity. Using that scope, the gallbladder was detached and removed through the incision behind the uterus. The area where the gallbladder was removed was then sutured. The three-hour outpatient procedure was performed to treat painful gallstones, which form when bile in the gallbladder hardens into pieces of stone-like material. Removal of the gallbladder is necessary in persistent and painful cases. A small and non-essential organ, the gallbladder stores and releases bile as part of the digestive process.

“This procedure marks the culmination of 15 years of advances that have made surgery less invasive in order to improve safety and reduce recovery time,” says Dr. Bessler, director of laparoscopic surgery and director of the Center for Obesity Surgery at NewYork-Presbyterian Hospital/Columbia University Medical Center and assistant professor of surgery at Columbia University College of Physicians and Surgeons. Beginning in the late 1980s, surgeons pioneered laparoscopic techniques for gallbladder surgery. Instead of the traditional 10-inch abdominal incision necessary for traditional open surgery, surgeons operated by inserting a camera and surgical instruments through a few small incisions. Nine out of 10 gallbladder surgeries are now performed this way. Natural-orifice surgery has been mainly confined to treating conditions within the gastrointestinal tract. However, the NOTES approach now goes a step further with this surgery — into the patient’s abdominal cavity. “Internal incisions, such as in the uterus, are less painful and may allow for quicker recovery than incisions in the abdominal wall,” says Dr. Bessler.

Science Daily
August 19, 2008

Original web page at Science Daily

Why do patients with gastric or pancreatic cancer live longer when they are treated at cancer centers or high-volume hospitals than patients treated at low-volume or community hospitals? New research from Northwestern University’s Feinberg School of Medicine found that cancer patients have more lymph nodes examined for the spread of their disease if they are treated at hospitals performing more cancer surgeries or those designated as comprehensive cancer centers. Lymph node metastases (indicating the spread of cancer) have been shown to predict patients’ prognosis after cancer tissue is removed from the stomach or pancreas. If too few lymph nodes are examined for malignant cells, a patient’s cancer may be incorrectly classified, which alters the prognosis, treatment decisions and eligibility for clinical trials. “The differences in nodal evaluation may contribute to improved long-term outcomes at cancer centers and high-volume hospitals for patients with gastric and pancreatic cancer,” said Karl Bilimoria, M.D., lead author of the paper and a surgical resident at the Feinberg School.

Current guidelines recommend evaluating at least 15 regional lymph nodes for gastric and pancreatic cancer, according to the study. Researchers reported that patients at a high-volume hospital or a hospital designated as a National Cancer Institute comprehensive cancer center or as part of the National Comprehensive Cancer Network were more likely to have at least 15 lymph nodes evaluated than patients undergoing surgery at community or low-volume hospitals. “Every reasonable attempt should be made to assess the optimal number of lymph nodes to accurately diagnose stage disease in patients with gastric and pancreatic cancer,” said Bilimoria, who also is a research fellow at the American College of Surgeons. “The status of patients’ lymph nodes is a powerful predictor of their outcome.”
Source: Archives of Surgery.

Science Daily
August 5, 2008

Original web page at Science Daily

A report by scientists from The Netherlands identifies a compound in human saliva that greatly speeds wound healing. This research may offer hope to people suffering from chronic wounds related to diabetes and other disorders, as well as traumatic injuries and burns. In addition, because the compounds can be mass produced, they have the potential to become as common as antibiotic creams and rubbing alcohol. “We hope our finding is ultimately beneficial for people who suffer from non-healing wounds, such as foot ulcers and diabetic ulcers, as well as for treatment of trauma-induced wounds like burns,” said Menno Oudhoff, first author of the report.

Specifically, scientists found that histatin, a small protein in saliva previously only believed to kill bacteria was responsible for the healing. To come to this conclusion, the researchers used epithelial cells that line the inner cheek, and cultured in dishes until the surfaces were completely covered with cells. Then they made an artificial wound in the cell layer in each dish, by scratching a small piece of the cells away. In one dish, cells were bathed in an isotonic fluid without any additions. In the other dish, cells were bathed in human saliva. After 16 hours the scientists noticed that the saliva treated “wound” was almost completely closed. In the dish with the untreated “wound,” a substantial part of the “wound” was still open. This proved that human saliva contains a factor which accelerates wound closure of oral cells. Because saliva is a complex liquid with many components, the next step was to identify which component was responsible for wound healing. Using various techniques the researchers split the saliva into its individual components, tested each in their wound model, and finally determined that histatin was responsible. “This study not only answers the biological question of why animals lick their wounds,” said Gerald Weissmann, MD, Editor-in-Chief of The FASEB Journal, “it also explains why wounds in the mouth, like those of a tooth extraction, heal much faster than comparable wounds of the skin and bone. It also directs us to begin looking at saliva as a source for new drugs.”

Science Daily
August 5, 2008

Original web page at Science Daily

A simple variation in a surgical technique developed at the University of Alabama at Birmingham (UAB) to reduce acute and chronic pain following lung surgery further reduces pain and helps return patients to normal activity quicker than the previous technique, according to a study published in the June issue of the Annals of Thoracic Surgery. Instead of crushing the intercostal muscle and nerve that lies between the ribs during rib spreading when performing a lung resection, UAB Chief of Thoracic Surgery Robert J. Cerfolio, M.D., teases the muscle and nerve away from the rib and then moves it out of the way before spreading the ribs. This leads to less trauma to the muscle and intercostal nerve and dramatically reduces post-operative pain. This new technique is a further modification of a concept that Cerfolio and colleagues reported in 2005. As reported in that paper, the technique divided, then moved, the intercostal muscle and the nerve away from the rib spreader so it was not crushed. In this new modification, the muscle is no longer divided but is allowed to dangle under the rib spreader, further avoiding trauma to the nerve and muscle.

For the 160 patients participating in this study, those who received the modified muscle flap technique reported that pain was reduced both in the hospital and after surgery at weeks three, four, eight and 12. Those who received the modified muscle flap procedure had lower pain scores and required less pain medications than those who did not. They also were more likely to return to normal activities within eight to 12 weeks after the surgery. The study used sophisticated, objective measurements of pain, including multiple pain score surveys, and measurements of patients’ pain medication usage. The original idea for the Cerfolio technique was generated from an earlier study Cerfolio published in the Annals of Thoracic Surgery in 2004. “In the first study, we found a way to avoid injury to the intercostal nerve that lies below the sixth rib during closure by drilling holes in the ribs so the closure stitches would not entrap that nerve,” Cerfolio said. “Then, I got the idea that maybe we could further reduce the pain by avoiding the intercostal nerve and muscle that lie above the sixth rib during opening and came up with the idea of harvesting the intercostal muscle flap prior to chest retraction. As surgeons, we are constantly looking for ways to improve techniques and reduce pain.” To date, a number of surgeons and other clinical staff from all over the world, including, Denmark, The Netherlands, Germany, France and Spain have recently come to UAB to observe Cerfolio perform lung surgery and learn this new technique. Cerfolio is recognized as one of the busiest thoracic surgeons in the world and performs more than 1,200 surgeries each year.

Science Daily
June 24, 2008

Original web page at Science Daily

A new surgical procedure for head and neck cancer at the University of Alabama at Birmingham offers improved accuracy for surgeons and reduced post-operative pain for patients. Initial tests have shown the new procedure also shortens recovery times for cancer patients. “This application takes robotic surgery to new places in the body,” said Carroll, a head and neck surgeon within UAB’s Division of Otolaryngology, and one of the first surgeons to begin using the procedure for head and neck cancers. “There is an option for patients to have a more minimally invasive surgery, and one that could effectively remove the cancer while causing fewer side effects,” he said.

Robotic surgery is an alternative to traditional open surgery and a refinement on the concept of laparoscopic surgery, Carroll said. The robot most commonly used in cancer treatment is called the da Vinci, which is sold by Intuitive Surgical. UAB was the first medical center in Alabama and among the first in the United States to begin using the da Vinci for head and neck cancers more than a year ago. Since that time, 40 UAB patients have had the new operation. Offering the new procedure to patients first involved adapting operating techniques and robot-arm positions, and continually refining those adaptations, Carroll said. The da Vinci was originally designed for operating on the lower and middle sections of the body, and the narrow spaces inside the head and neck can be a challenge. The increased surgical accuracy comes from tiny cameras attached to the end of the da Vinci instruments. Carroll said the magnified, 3-D image gives doctors a greater field of vision than conventional open or laparoscopic surgery.

Science Daily
May 13, 2008

Original web page at Science Daily