Tag: Surgery (Orthopeadics)

Using a novel surgical approach, it’s possible to rebuild the trachea and preserve a patient’s voice after removing an invasive throat tumor, according to a new report from Henry Ford Hospital in Detroit. This case study is the first of its kind to not only document a successful technique to create a fully functional trachea, or windpipe, but also report a rare type of malignant tumor in an adult’s trachea. Most commonly, this type of tumor is seen in newborns and very rarely occurs in the neck, says lead study author Samer Al-Khudari, M.D., with the Department of Otolaryngology-Head & Neck Surgery at Henry Ford Hospital. “In this case, the patient’s tumor had spread to the trachea, thyroid gland, muscles around the thyroid gland and nerves in the area,” says Dr. Al-Khudari. According to head and neck cancer surgeon Tamer A. Ghanem, M.D., Ph.D., who led the Henry Ford surgical team, the easiest approach would have been to remove the trachea and the voice box, given the tumor’s proximity to the larynx and other surrounding structures. With this method, however, the patient would no longer be able to speak or swallow normally.

Instead, the surgical team took another approach. Using tissue and bone from the patient’s arm, they were able to reconstruct the trachea, restoring airflow through the trachea and saving the patient’s voice. “We had to think outside the box to not only safely remove the tumor, but to allow for optimum functional outcome,” says Dr. Ghanem, director of the Head and Neck Oncology & Microvascular Surgery Division at Henry Ford. “This is the first time such a large portion of a patient’s trachea has been removed and rebuilt in a way that allows it to be fully functional.” This unique case will be presented Jan. 29 at the poster session for the Triological Society’s Combined Section Meeting in Scottsdale, Ariz. The case study is centered on a 27 year-old man who had a large mass blocking 90 percent of his airway, making it very difficult for him to breathe. After a biopsy and other tests, Henry Ford doctors determined the mass was a malignant immature teratoma — a cancerous tumor that was quickly spreading throughout the areas of the patient’s trachea and surrounding structures.

Such tumors are extremely rare; since the first reported case in 1854, there have only been 300 other reported cases. With the Henry Ford patient, surgeons first removed the tumor and about half of the patient’s airway, just below the voice box. Using bone and skin from the patient’s arm and two titanium plates, surgeon’s reconstructed the airway, providing it with full coverage and allowing it to be fully functional. Reconstruction of the trachea is challenging, due to the structural complexity and unique properties of the airway. The ideal reconstruction must not collapse during respiration and have some degree of mobility to allow for neck movement. Currently the patient is using a tracheostomy tube — a tube that is inserted into an opening in the trachea to assist with breathing — but the surgeons do not expect it to be permanent. The patient, however, is able to speak and swallow normally. He also underwent chemotherapy as part of his treatment.

Science Daily
February 8, 2011

Original web page at Science Daily

Robot-assisted surgery dramatically improves outcomes in patients with uterine, endometrial, and cervical cancer, said researchers at the Jewish General Hospital’s Lady Davis Institute for Medical Research in Montreal. Moreover, because of fewer post-operative complications and shorter hospital stays, robotic procedures also cost less. These results were published in late 2010 in a series of studies in The Journal of Robotic Surgery and The International Journal of Gynecological Cancer. To date, adoption of robotic surgery has been slowed by fears that it will raise overall healthcare costs. In Canada, robotic procedures are not yet covered by any provincial healthcare plan. “To the contrary, robotic surgery definitely benefits patients and society,” said Dr. Walter H. Gotlieb, Head of Gynecologic Oncology at the JGH Segal Cancer Centre. “Patient quality of life is dramatically improved, their hospital stays are much shorter and they use far less narcotic pain medication. The majority of our patients need nothing stronger than Tylenol.”

In a robot-assisted operating room, the physician sits at a computer console and manipulates multiple robot arms, rather than working directly on the patient. The technology was developed to overcome the limitations of minimally invasive surgery (MIS), including such notoriously difficult procedures as laparoscopy for cancer. “Laparoscopy is the gold standard of treatment for endometrial cancer, but unfortunately the learning curve is too steep for most surgeons,” said Dr. Gotlieb, also Director of Surgical Oncology at McGill University. “A recent U.S. study said that only about six percent of gynecologic oncology surgeons offer laparoscopy to most of their endometrial cancer patients, despite its well-established advantages.” “At the Jewish General Hospital, we went from only 15 percent of our endometrial cancer patients benefiting from MIS by laparoscopy to 95 percent using robotic surgery. In cervical cancer we did not perform MIS at all before, whereas now all of our patients benefit from it.”

Moreover, contrary to Isaac Asimov and other 20th-century science fiction writers, who predicted that people would react to robots with fear and loathing, patients — even elderly patients- are the most enthusiastic boosters of robotic surgery. In a letter addressed to the hospital’s director of professional services, one patient with a very complex case of endometrial cancer heaped praise on her “surgeon and his robot” and called the device a “marvel.”

Science Daily
January 24, 2011

Original web page at Science Daily

Laparoscopic or ‘keyhole’ surgery is a safe, effective way of removing bowel tumours and should be offered to all patients undergoing surgery for colorectal cancer, according to researchers from the University of Leeds. Patients who have laparoscopic surgery spend less time in hospital and recover more quickly from the operation. Now long-term follow-up data has confirmed that this way of doing surgery does not make patients with colorectal cancer more vulnerable to the disease returning, as some had feared. And overall survival rates for keyhole surgery are just the same as those for conventional, open surgery, researchers concluded after tracking the progress of patients for five years. The results are the latest from the CLASICC trial — a multicentre study funded by the Medical Research Council that involved around 400 patients with colon cancer and another 400 with rectal cancer. The trial drew on patients from 27 hospitals across the UK and unlike other head-to-head assessments of these two surgical techniques, included a detailed analysis of all tissue samples that were removed to assess the quality of surgery.

Initial results from the study, published previously, showed that keyhole surgery was as safe as open surgery for colorectal cancer and that in the short term the cancer was no more likely to return. These findings contributed to the decision by the UK National Institute of Clinical Excellence (NICE) and European regulators to back the use of laparoscopic techniques by surgeons for the treatment of colon and bowel cancers. However, some surgeons were concerned that the minimally invasive technique would not be as good at removing all cancer cells from tissue around the tumour and that after a few years, the cancer would simply come back. This risk was thought to be highest for patients with rectal cancer. These latest findings show that this is not the case and that in the hands of an experienced surgeon, the chance of colorectal cancer recurring does not depend on the surgical method. Also, the overall survival rate of patients with colorectal cancer is not affected by the type of surgery they have. Full details are published in the November issue of the British Journal of Surgery.

“There is still a body of surgeons who are sceptical about laparoscopic colorectal cancer surgery and particularly laparoscopic rectal surgery. These long-term follow-up results should now help to convince any remaining sceptics that the minimally invasive technique is safe and effective for most patients with colorectal cancer,” said David Jayne, Senior Lecturer in Surgery at the University of Leeds and lead author of the paper. “Patients too should be reassured that any short-term gains from minimally invasive surgery have not been at the expense of compromised long-term outcomes,” he said. “Where suitable, laparoscopic surgery should now be offered to all patients with colorectal cancer so that they can benefit from the recognised advantages, such as quicker recovery, shorter hospital stay and earlier return to normal function.” “Surgery remains the most important of the methods of treatment of bowel cancer and this study confirms that tumours can be removed equally well by keyhole surgery as by standard surgery. We must, however, continue to strive for surgical excellence through audit of both types of surgery and by exploration of new techniques, such as robotic surgery,” said Professor Phil Quirke, Yorkshire Cancer Research Centenary Professor of Pathology at the University of Leeds, and co-author of the paper.

Science Daily
November 23, 2010

Original web page at Science Daily

Physicians at Mayo Clinic’s Florida campus are among the first in the nation to use a technique known as MRI-guided laser ablation to heat up and destroy kidney and liver tumors. So far, five patients have been successfully treated — meaning no visible tumors remained after the procedure. Although the treatment techniques are in the development stage, the physicians say the treatment is potentially beneficial against most tumors in the body — either primary or metastatic — as long as there are only a few in an organ and they are each less than 5 centimeters in size (about 2 inches in diameter). Patients also cannot have a pacemaker or certain metallic implants, since the procedure is done inside an MRI machine. “Laser ablation offers us a way to precisely target and kill tumors without harming the rest of an organ. We believe there are a lot of potential uses of this technique — which is quite exciting,” says Eric Walser, M.D., an interventional radiologist who has pioneered the technique at Mayo Clinic, Florida. In the United States, laser ablation is primarily used to treat brain, spine and prostate tumors, but is cleared by the U.S. Food and Drug Administration (FDA) for any soft tissue tumor.

Only a few centers have adapted the technique to tumors outside of the brain. Dr. Walser has been using laser ablation since June. He learned the technique in Italy, where its use is more common, and he adapted it for patients at Mayo Clinic, Florida, many of whom are on a liver transplant waiting list. The clinic is a large liver transplant center, and a number of patients with cirrhosis have small tumors in their liver. “We treated the tumors to keep them at bay because we could not use chemotherapy in these patients, who are quite ill and are waiting for a new liver,” he says. He also adapted it for use in treating kidney tumors. The outpatient procedure is performed inside an MRI machine, which can precisely monitor temperature inside tumors. A special nonmetal needle is inserted directly into a tumor, and the laser is turned on to deliver light energy. Physicians can watch the temperature gradient as it rises, and they can see exactly in the organ where the heat is. When the tumor and a bit of tissue that surrounds it (which may harbor cancer cells) is heated to the point of destruction — which can be clearly seen on monitors — the laser is turned off. In larger tumors, several needles are inserted simultaneously.

Patients are given anesthesia because, during the 2.5-minute procedure they should not move, Dr. Walser says. Post-treatment side effects include some local pain and flulike symptoms as the body reacts to, and absorbs, the destroyed tissue, he says. These side effects usually subside in three days to one week. Dr. Walser adds that laser ablation is a much more precise technology than similar methods that use probes, such as radiofrequency ablation, which also raises a tumor’s temperature, and cryotherapy, which freezes tumors. At the March meeting of the Society of Interventional Radiology, Dr. Woodrum, presented results from the first known cases of using MRI-guided laser ablation to treat prostate tumors. He said then that the safe completion of four clinical cases using the technique to treat prostate cancer in patients who had failed surgery “demonstrates this technology’s potential.”

Mayo Clinic
October 26, 2010

Original web page at Mayo Clinic

A team of surgeons from Mt. Sinai Hospital in New York who have pioneered scar-free gallbladder removal are offering the procedure to all suitable patients and extending this new type of surgical procedure to other operations in the abdomen. They reported on their updated findings October 6 at the 2010 Annual Clinical Congress of the American College of Surgeons. The procedure is known as laparoendoscopic single-site surgery, or LESS. It marries laparoscopy, known commonly as minimally invasive surgery that requires small incisions in the abdomen to insert instruments, with endoscopy, a probe with a camera that lets the surgeon see inside the abdomen. Laparoscopy is an alternative to an open operation, which involves a large incision to actually open the surgical site. The LESS procedure goes one better than minimally invasive surgery, according to study coauthor Edward Chin, MD, FACS, a general surgeon at Mt. Sinai Medical Center in New York. “Minimally invasive gallbladder surgery requires the surgeon to make four small incisions in a half-moon pattern in the abdomen, but the LESS procedure requires one incision made through the navel. Moreover, laparoscopy leaves behind four visible, small scars in the abdomen following a procedure. LESS leaves virtually none,” he said.

The LESS approach to gallbladder surgery is not for everyone, Dr. Chin cautioned. Patients who need emergency surgery or who have had previous abdominal operations that built up scar tissue are probably not suitable candidates. “Those two populations aside, we try to offer this technique to everyone who is coming in for elective laparoscopic gallbladder surgery,” he explained. So far, results with LESS have been almost identical to those with laparoscopic surgery, Dr. Chin reported. Both operations typically allow for same-day discharge and require similar recovery times before patients return to their normal activities, and the costs for both are similar. “The surgeon can use a lot of expensive, new disposable instruments, but we are more inclined to use the minimum of specialized equipment,” Dr. Chin explained. “Depending on what available equipment the surgeon chooses to use, you can keep the costs relatively low, and not significantly higher than a traditional laparoscopic operation.”

The Mt. Sinai group did find two advantages to the LESS procedure: these patients required less pain medicine after the operation than their counterparts who had the traditional minimally invasive operation; and LESS patients typically reported higher satisfaction scores: –4.7 on a scale of 1 to 5 (5 equals highest score) versus 3.6 for the conventional laparoscopic surgery group. “What’s really exciting is how these patients would recommend the procedure to a friend or family member,” Dr. Chin said. “Seventy-four percent of the patients who had the single-incision operation would strongly recommend the procedure to someone else versus 36 percent of those who had laparoscopic surgery.” Since the Mt. Sinai team first used LESS for gallbladder removal, the surgeons have completed operations using the LESS approach to remove adrenal glands and spleens, Dr. Chin said. “These are more advanced and challenging procedures, but we were able to demonstrate in small numbers so far that these procedures can be safely done using a similar technique,” he said. However, he added, these procedures require more study. Earlier this year, the Mt. Sinai surgeons also completed a single-incision combined operation, removing the gall-bladder and spleen in a pediatric patient, Dr. Chin reported.

Future innovations related to the procedure may involve incorporating surgical robots, Dr. Chin said. “For gallbladder removal, very few surgeons would employ the surgical robot because it’s just not necessary,” he said. “Gallbladder surgery is a relatively straightforward procedure that can be done very well and very safely by traditional surgery.” Additionally, today’s robots are too large and expensive to use for common abdominal operations, he said. “When the surgical robot gets further miniaturized, I can see this really revolutionizing single-incision surgery,” he added.

Science Daily
October 26, 2010

Original web page at Science Daily

Delayed hepatic arterial hemorrhage after pancreaticoduodenectomy (PD) is not a common but a fatal complication, occurring in 7% of all patients. Its ideal management remains unclear and controversial. A research article published on August 7, 2010 in the World Journal of Gastroenterology addresses this question. The authors reported the clinical outcome of 9 patients with life-threatening hemorrhage from a ruptured hepatic artery pseudoaneurysm after PD after treatment with a new interventional technique, namely placement of stent-grafts. This technique provides a good alternative option for the control of hemorrhage from ruptured hepatic artery pseudoaneurysm after PD, especially in those who cannot undergo embolization. Although the number of patients was small, the procedure demonstrated a lower mortality than conventional surgical intervention. Based on their results, placement of stent-grafts for acute lifethreatening bleeding from hepatic artery pseudoaneurysm is a valuable alternative to embolization and surgical intervention. If technically possible, this technique should be considered the first-line treatment for bleeding from the common and proper hepatic artery, particularly in patients with a non-portal vein. Further data are required to evaluate its technical success rate, complications, and long-term outcome in a larger number of patients.
Reading more:http://www.wjgnet.com/1007-9327/full/v16/i29/3716.htm

Science Daily
October 12, 2010

Original we page at Science Daily

Surgeons at the University of California, San Diego, School of Medicine and University of Washington Medical Center have determined that transorbital neuroendoscopic surgery (TONES) is a safe and effective option for treating a variety of advanced brain diseases and traumatic injuries. This groundbreaking minimally invasive surgery is performed through the eye socket, thus eliminating the removal of the top of the skull to access the brain. These findings were published in the September issue of Neurosurgery. “By performing surgery through the eye socket, we eliminate the need for a full craniotomy, gain equivalent or better access to the front of the brain, and eliminate the large ear-to-ear scar associated with major brain surgery,” said Chris Bergeron, MD, assistant professor of Surgery, Division of Head and Neck Surgery, at UC San Diego Health System. “This novel technique is also critical to protecting neurovascular structures such as the optic and olfactory nerves.”

To achieve access, the surgeons make a small incision behind or through the eyelid. A tiny hole is then made through the paper-thin bone of the eye socket to reach the brain. This pathway permits repairs to be made without lifting the brain. The TONES approaches also protect the optic nerves, the nerves for smell, as well as the carotid and ophthalmic arteries. “This approach has opened a new field of brain surgery,” said study investigator, Kris Moe, MD, chief of the Division of Facial Plastic and Reconstructive Surgery and professor of Otolaryngology at University of Washington Medical Center. “The advantages to this transorbital approach are many, including reduced pain and decreased recovery time for the patient.” Transnasal surgery, a technique performed through the nose, offers similar access to some areas of the brain but means a more crowded operating environment for the surgeon than TONES. Moe, who pioneered the TONES in 2005, said the novel technique builds on the nasal approach but offers increased maneuverability and visibility for the surgical teams which usually require four sets of hands.

In a traditional craniotomy, a large portion of skull bone is removed. With TONES, the area of bone removed is only two to three centimeters. The operating time is much shorter since the skull does not need to be repaired and there is no need to close a large incision. Patients underwent the TONES procedure to repair cerebral spinal fluid leaks, optic nerve decompression, repair of cranial base fractures and removal of tumors. Given further research, the surgeons believe that TONES may serve as a means to treat pituitary tumors, meningiomas, and vascular malformations. TONES is currently performed at only two institutions in the world: UC San Diego Medical Center and the University of Washington Medical Center.

Science Daily
October 12, 2010

Original web page at Science Daily

Using the same technology found in clothing tags used in retail store tracking systems, a study from the University of North Carolina at Chapel Hill shows that surgical sponges with implanted radio frequency (RF) tags may be an effective adjunct to manual counting and X-ray detection in preventing sponges from being left behind in patients following a surgical procedure. UNC surgeons will report the preliminary results of the study on Tuesday, Oct. 5 during a poster session at the 2010 Annual Clinical Congress of the American College of Surgeons in Washington, D.C. The reported incidence of a sponge or another foreign body, such as a surgical instrument, being left behind after operations has varied widely over the years. Previously published reports have estimated ranges of one in 1,000 operations to one in 18,000. Our preliminary data agrees with the previously reported incidence of retained surgical sponges,” said lead investigator UNC gastrointestinal surgeon Christopher C. Rupp, MD. The researchers used a radio-frequency (RF) detection device in 1,600 operations, and found a sponge in one operation in which manual counting of the sponges was correct.

Sponges used to absorb fluids and improve access to organs during surgical procedures are much different than household sponges. Surgical sponges are mostly made of cotton, and come in sizes of 12-by-12 inches or as small as 4-by-4 inches. These sponges can become difficult to see during an operation because they can mold into different shapes and take on the same color of the fluids being absorbed. Furthermore, the sponges can migrate to other areas of the operative field, and they can be difficult to feel with surgical gloves. Surgeons use various methods to track sponges during operations. The most common is manual sponge counts by a nurse, but more sophisticated methods include the radio-frequency tagged sponges used in the UNC study, X-ray of the abdomen and bar-coded sponges. The UNC investigators did not include bar-coding systems in their study. Human error involved with manual counting and X-ray interpretation were the impetus that resulted in the studies inception, Rupp reported. The RF-tagged system in the UNC study has the same technology found in the clothing tags used in retail store tracking systems and in microchips embedded in pets. During surgery, a nurse passes a wand over the patient’s body to pick up readings from the RF tags. Newer versions have detection hardware built into the mat the patient lies on. “RF detection is not going to replace counting in the operating room, but it can be used as an adjunct because, from what we’re seeing in the preliminary data, it adds a lot to the safety of the procedure,” Rupp said.

Science Daily
October 12, 2010

Original web page at Science Daily

Sepsis and septic shock appear to be more common than heart attacks or pulmonary blood clots among patients having general surgery, and the death rate for patients with septic shock is approximately 34 percent within 30 days of operation, according to a report in the July issue of Archives of Surgery, one of the JAMA/Archives journals. “Prevention of perioperative complications is a major focus in the care of the general-surgery patient,” the authors write as background information in the article. In recent years, attention has been focused on prevention of venous thromboembolism (including post-operative deep vein thrombosis, or blood clots in the deep veins of the pelvis or extremities, and pulmonary embolism, or blood clots that travel to the lungs), myocardial infarction (heart attack) and surgical site infections. These efforts have resulted in awareness and reduction of these complications.

Sepsis, an infection that usually results from bacteria in the bloodstream and can result in failure of multiple organ systems, is another potentially preventable cause of illness and death in general surgery patients, the authors note. Laura J. Moore, M.D., and colleagues at The Methodist Hospital, Weill Cornell Medical College, Houston, reviewed the incidence, mortality rate and risk factors for sepsis in general surgery patients using data from the 2005 to 2007 American College of Surgeons National Surgical Quality Improvement Program. Of 363,897 general surgery patients, sepsis occurred in 8,350 (2.3 percent), septic shock or life-threatening low blood pressure due to sepsis occurred in 5,977 (1.6 percent), pulmonary embolism occurred in 1,078 (0.3 percent) and heart attack occurred in 615 (0.2 percent). Death rates within 30 days were 5.4 percent for sepsis, 33.7 percent for septic shock, 9.1 percent for pulmonary embolism and 32 percent for heart attack.

The results suggest that sepsis continues to be a common and serious complication in general surgery patients and occurs more frequently than pulmonary embolism or heart attack. “Of note, septic shock occurs 10 times more frequently than myocardial infarction and has the same mortality rate; thus, it kills 10 times more people,” the authors write. “Therefore, our level of vigilance in identifying sepsis and septic shock needs to mimic, if not surpass, our vigilance for identifying myocardial infarction and pulmonary embolism.” Risk factors for sepsis and septic shock included age older than 60, the need for emergency surgery and the presence of any co-occurring illness. Having such an illness increased the risk of sepsis and septic shock six-fold and the risk of dying within 30 days 22-fold. “By identifying three major risk factors for the development of and death from sepsis and septic shock in general-surgery patients, we can heighten our awareness for sepsis and septic shock in these at-risk populations,” the authors conclude. “The implementation of mandatory sepsis screening for these high-risk populations has resulted in decreased sepsis-related mortality within our institution. Further evaluation of the role of sepsis screening programs in other settings is critical and could significantly reduce sepsis-related mortality in general-surgery patients.”

Science Daily
August 3, 2010

Original web page at Science Daily

A new study spearheaded by Spanish scientists demonstrates a causal relationship between the onset of Creutzfeldt-Jakob disease (CJD), caused by a protein called a prion, and general surgery. CJD manifests itself in hereditary acquired and sporadic forms, or for unknown reasons, which accounts for the majority of cases. “Based on the monitoring records of spongiform encephalopathy in two Nordic countries, we studied the possibility of transmission of the sporadic form of CJD through general surgery,” explains Jesús de Pedro, main author of the study and head of prion monitoring in patients at the National Epidemiology Centre of the Carlos III Health Institute. The finding, published recently in the Journal of Neurology, Neurosurgery & Psychiatry, reveals that, with a few exceptions, the risk of having contracted the sporadic form of CJD manifests itself at least 20 years after having undergone an operation.

“While we are not ruling out the idea that intraoperational transfusions may play a secondary part, the data suggest that the disease enters and spreads much more quickly within the central or peripheral nervous system,” says De Pedro. According to the authors, the fact that computer records of surgeries have been in place since the early seventies in hospitals in Sweden and Denmark enables operations on residents of those countries to be linked to cases of CJD, which “extends an extraordinary quality to the information and more credibility to the findings given the almost total absence of memory bias.” Why is the idea of transmission through surgery important? The most interesting thing about this finding, which points to an external cause that could be prevented, is that “it may signify a shift in our understanding of the nature of neurodegenerative diseases, such as Alzheimer’s or Parkinson’s.” We might, therefore, ask ourselves if other types of motor neuron diseases can be transmitted through surgery and be latent for decades, such as those where risk factors, particularly physical professions and activities or certain sporting activities, for example, which are more likely to lead to surgery, have already been indicated.

“Suggesting that a disease could have been acquired during health care is a very delicate affirmation, as some relatives of patients with sporadic CJD may be tempted to seek compensation from health authorities for the alleged intraoperational transmission years previously, which would be impossible to prove in individual cases,” he reasons. Nonetheless, the most conclusive pattern that the study presents, albeit based on few cases and one that must be replicated in future studies, is that the onset of CJD occurs approximately 10 years after an operation on the retina with reused equipment.

Science Daily
July 20, 2010

Original web page at Science Daily

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