Outcomes after abdominal aortic aneurysm repair: comparison of mortality defined by centralized VA Patient Treatment File data versus hospital-based chart review

BACKGROUND: Outcomes after abdominal aortic aneurysm (AAA) repair have been reported by individual Veterans Affairs medical centers (VAMCs) and for the entire VA patient population. PURPOSE: This study was done to determine whether outcomes defined using VA Patient Treatment File (PTF) data were comparable to those defined by direct chart review in those undergoing repair of intact AAA. METHODS: Focused chart review was performed in all veterans undergoing such AAA repair in a sample of VAMCs (n = 5) for separate 1-year periods during fiscal years (FY) 1991-1993. A previous report of outcomes after AAA repair for all veterans in DRGs 110 and 111 during FY 1991-1993 was based on PTF data that were further analyzed by Patient Management Category (PMC) software. Outcomes after AAA repair were defined in a similar fashion using PTF data and PMC analysis in the same sample VAMCs for which direct chart review data were available. Outcomes defined by chart review were then compared to those based on PTF data. RESULTS: Three of the 69 patients undergoing repair of intact AAA for which chart review data were available were assigned to DRGs other than 110 and 111 and, by definition, were not included in the PTF-derived database. Nine of 10 additional patients undergoing chart review were not identified as having undergone AAA repair by PMC software: 7 had procedure codes 39.25 instead of more standard AAA repair codes 38.34 or 38.44. Two additional patients with codes 38.64 or 38.66 were not identified as having undergone AAA repair by PMC software. The 10th patient not included in the PTF-derived database underwent additional operative procedures. Of the 13 patients missed by the combined PTF and PMC outcome analyses but identified by chart review, none died or had cardiac complications. One of these 13 patients had pulmonary complications based on chart review and PTF but was excluded by PMC analysis. There remained a total of 56 patients at the five sample VAMCs common to the PTF-derived and chart-derived databases identified as having undergone repair of intact AAA. There were two in-hospital deaths in these patients, and both were identified by each approach to outcome assessment. Four of these 56 patients had postoperative cardiac complications (ICD-9-CM code 997. 10) which were identified by both PTF and chart review. Postoperative pulmonary complications (ICD-9-CM code 997.30) were present in 4 of the 56 cases and were also identified by both PTF-based and chart-based outcome analyses. CONCLUSIONS: All deaths as well as cardiac or respiratory complications identified by chart review at the study hospitals were also affirmed by the PTF. Due to study methodologies (which restricted analysis to those in DRGs 110 and 111 and which included secondary analyses of PTF data by PMC software), 19% of patients who underwent repair of intact AAA identified by hospital-based chart review were excluded from the PTF-based outcome analysis. Outcomes defined using large databases such as the VA PTF may be comparable to those defined by chart review if study methodologies permit. Discrepancies in outcome assessment between direct chart review and large database analysis in the present study were due to methodologies used, not to deficiencies, per se, in PTF data.     

Common risk factors seen in secondary carpal tunnel surgery

BACKGROUND: We hypothesized that there are several common risk factors associated with secondary carpal tunnel releases. Therefore, we chose to investigate these common factors by analyzing the charts of those patients requiring a second carpal tunnel release (CTR) procedure. METHODS: A retrospective chart review was performed, and patients were identified by searching hospital medical record databases using the Common Procedural Terminology. RESULTS: Between January 1, 2000, and March 31, 2004, 2357 patients had a primary CTR, and 48 of them were found to have had a secondary CTR (of these 48, 9 had diabetes mellitus, 11 had hypertension, and 6 had gastrointestinal-related illnesses). Seven percent of those who had an open release primarily required a second CTR, while only 0.2% of those who had an endoscopic release primarily required a second CTR. CONCLUSION: A greater number of secondary CTR procedures were required for those patients with symptoms of carpal tunnel syndrome in the group that had an open release primarily versus those that had an endoscopic release primarily. Diabetes mellitus and hypertension may also contribute to the need for secondary surgery.     

Calcaneal fractures in the industrial patient

A retrospective review was performed on industrial patients who sustained calcaneal fractures within the State of Idaho during the years 1992 to 1994, and these patients were insured by the Idaho State Insurance Fund. Of 48 calcaneal fractures that occurred during this period, 18 were non-displaced extra-articular fractures and 30 were displaced intra-articular fractures. An independent evaluator contacted each patient and performed chart reviews regarding the work history, period of time off work, and cost incurred with the injury. A total of 24 primary surgical procedures were performed on patients who sustained a displaced intra-articular calcaneal fracture and 31 secondary procedures were performed including wound debridement, hardware removal, skin grafting, and secondary subtalar fusion. For patients whose calcaneal fractures could be treated with non-operative care, the average time from injury until return to work was 18 weeks, and the average total cost of injury was $14,230. For patients whose calcaneal fractures required open reduction and internal fixation, the average time loss from work was 35 weeks, and the average total cost of injury was $31,004. Seven patients whose calcaneal fractures were initially treated with an open reduction, internal fixation later underwent a hindfoot arthrodesis. The average time off work for these patients was 69 weeks and the average total cost of injury was $65,384. Fractures were rated on postoperative radiographs according to the quality of their operative reduction. Fractures that were non-anatomically reduced had an increased tendency to require a subtalar fusion. Nine patients sustained other injuries associated with their calcaneal fracture and three patients sustained an open fracture. Both concurrent injuries and open fractures were associated with increased total cost and increased time off work. The total cost of injury was doubled as was time off work when an open reduction and internal fixation was followed later by a secondary subtalar arthrodesis.     

Endoscopic and endoscope-assisted resections of inverted sinonasal papillomas.

OBJECTIVE: To evaluate the success of endoscopic and endoscope-assisted resection of inverted sinonasal papillomas and to assess the indications for adjunctive external procedures. STUDY DESIGN: Retrospective chart review. RESULTS: Fifty patients were treated surgically during the 10-year study period and had greater than 1 year of follow-up care. These patients had a recurrence rate of 14% (7/50) with a mean follow-up of 31.1 months. Of these 7 patients with recurrences, 3 were treated primarily at this institution, and 4 had been treated prior to referral. Recurrence was 11% (3/27) for primary resections and 17% (4/23) for secondary resections. Average time to recurrence was 11.7 months. Of the patients, 38% (19/50) had adjunctive external procedures either during the initial resection or for the management of recurrent disease. CONCLUSIONS: Endoscopic and endoscope-assisted resections of inverted papilloma are effective techniques for managing inverted papilloma. The intraoperative findings, most importantly the site(s) of tumor attachment, dictate whether an endoscopic procedure is sufficient to complete resect the inverted papilloma or whether an adjunctive external procedure is required. Appropriate patient selection and an aggressive surgical approach are necessary for the management of these neoplasms.     

Routine chest X-ray after percutaneous tracheostomy is unnecessary

Percutaneous tracheostomy (PT) is an increasingly common procedure in the management of critically ill patients. Current practice for both open and percutaneous tracheostomies is a post-procedure chest X-ray to rule out potentially life-threatening complications such as a pneumothorax or tube malposition. Our study evaluated the utility of chest X-ray after PT. A retrospective chart review was conducted for patients undergoing PT at Kern Medical Center between January 1999 and December 2003. Charts were reviewed for age, sex, and clinical outcome as well as the radiologist's interpretation of the postprocedure chest X-ray. A total of 73 procedures were completed in 47 men and 26 women. The majority of the tracheostomies were in trauma patients who needed prolonged ventilatory support. There were no complications identified on postprocedure chest X-ray. A single patient was converted to an open procedure secondary to bleeding. We conclude that routine chest X-ray after PT is unnecessary.     

Gender differences in surgical treatment of patients with cleft lip and palate

Numerous gender-based differences in medical treatment have been recognized due to conscious or unconscious perceptions, i.e. gender bias. The aim of the present study was to investigate whether gender differences exist in the surgical treatment of patients with cleft lip and palate (CLP) anomalies. This study is a retrospective review of 235 consecutive patients with non-syndromic unilateral CLP or bilateral CLP born between 1966 and 1986. Each chart was reviewed, and 2178 surgical procedures were registered and categorized as primary surgery (primary lip, palatal and alveolar repair) or secondary surgery (aesthetic and functional revision). Different surgical procedures could be performed during the same surgical session. The number of surgeries performed was analysed and compared between genders. The results demonstrate that women with CLP received statistically significantly more secondary surgeries than men. No differences in the number of primary surgeries were identified. This study provides a gender perspective of the treatment of CLP. We identified no gender differences in primary surgery of the CLP. The standardized method of repairing the cleft is effective in preventing unjust treatment due to gender. However, we identified an indication of gender bias in cleft care regarding secondary surgeries of the nose and lip, namely, women are over-treated and/or men are under-treated. There are several possible explanations for this phenomenon, and further studies are needed.     

Incidence of radiographic unicompartmental arthritis in patients undergoing knee arthroplasty

Unicompartmental knee arthroplasty is increasing in popularity with the advent of less invasive procedures for knee arthritis. The percentage of patients undergoing knee arthroplasty who could be candidates for unicompartmental knee arthroplasty depends on the surgeon's evaluation of the radiographs, and this evaluation may depend on the surgeon's bias regarding partial knee arthroplasty. A retrospective radiographic and chart review was performed on a consecutive series of patients who had undergone tricompartmental knee arthroplasty to determine the percentage of those patients who could have been candidates for unicompartmental knee arthroplasty. Two hundred eighty-eight patients who underwent 308 tricompartmental knee arthroplasties over a 3-year period at a Veteran's Administration Hospital comprised the study group. Assessment of preoperative radiographs was done by 2 surgeons, 1 who favored unicompartmental knee arthroplasty and the other who preferred tricompartmental knee arthroplasty, to determine the percentage of these patients, from each surgeon's viewpoint, who had unicompartmental arthritis. Patients who had radiographic unicompartmental arthritis were then eliminated as candidates for unicompartmental knee arthroplasty, if, on chart review, they had a flexion contracture >10°, an arc of motion <100°, or inflammatory arthritis. The surgeon who was a proponent of unicompartmental knee arthroplasty found that 26% of these patients had acceptable radiologic and clinical indications for unicompartmental knee arthroplasty, whereas the surgeon who had a bias against the procedure felt that only 12% of these patients were unicompartmental knee arthroplasty candidates. A considerable percentage of Veteran's Administration patients undergoing arthroplasty for knee arthritis may be potential candidates for unicompartmental knee arthroplasty, despite the surgeon's bias for or against the procedure.     

Trauma laparotomy in a rural setting before transfer to a regional center: does it save lives?

BACKGROUND: In the rural setting, long distances may necessitate that a patient undergo emergency laparotomy before transfer to a regional trauma center for definitive management. The purpose of this study was to review the experience of three regional trauma centers with such treated patients. METHODS: This study was a retrospective chart review of patients who underwent emergency laparotomy for trauma before transfer, identified from the respective databases of participating centers over a 6-year period. RESULTS: Fifty-six patients met the study criteria. Twenty-six (46%) were transferred primarily for management of the abdominal injury, and 14 of these patients (25% overall) underwent damage control procedures. Overall survival was 82%. Logistic regression demonstrated that transfer for treatment of the extra-abdominal injury was the only significant predictor of survival (odds ratio, 34.33; 95% confidence interval, 1.80-655.24). CONCLUSION: Although patients undergoing laparotomy who were subsequently transferred for management of abdominal injury have reasonable outcome, patients transferred primarily for management of extra-abdominal injury seem to have a survival advantage.     

Predicting complications in elderly patients undergoing lumbar decompression

A retrospective chart review of 68 patients 70 years of age or older who underwent decompressive procedures of the lumbar spine with or without fusion for benign conditions was performed to determine the ability of preoperative assessment of medical comorbidities to predict early postoperative complications. Patients 70 years of age or older who underwent decompressive procedures on the lumbar spine with or without fusion from January 1, 1990 to June 30, 1996 were identified. A chart review focused on preoperative comorbid diseases and early postoperative complications. A telephone survey was performed to assess patient satisfaction. Thirty-four women and 34 men with an average of 76.5 years averaged 1.6 comorbidities. Thirteen patients did not have comorbidities. The weighted comorbidity index resulted in an average score of 1.9. Eighty-five percent of the patients underwent posterolateral fusion. The total complication rate was 40%. Serious complications potentially affecting quality of life occurred in 12% of patients. The early mortality rate was 1.4%. The authors were unable to show a significant relationship between comorbidities and postoperative complications. Seventy-one percent of the 44 patients who were contacted at an average 42 months postoperatively were satisfied with their outcome. Elderly patients can safely undergo lumbar spinal procedures with an outcome similar to younger patients.     

Minimally invasive surgical techniques in reoperative surgery for gastroesophageal reflux disease in infants and children

Fundoplication is commonly performed in children suffering from complications of gastroesophageal reflux disease (GERD). Recently laparoscopic fundoplication has become a standard of care for GERD in children. Published reports show that 2.3 to 14 per cent of children require reoperation after failed fundoplication. The purpose of this study is to show the feasibility of minimally invasive surgical (MIS) techniques to treat children after failed fundoplication. A retrospective chart review was performed for all patients who underwent laparoscopic redo fundoplication at Children's Healthcare of Atlanta at Egleston from July 1998 to July 2000. The patients' records were reviewed for age, diagnosis, type and time of initial operation, type and time of redo operation, operative time for redo operation, and complications. Seventeen children (age 3 months to 18 years) had operations for failed fundoplication attempted using MIS techniques. Six of these children were referred after their initial operation performed elsewhere. Nine (53%) were neurologically impaired. Ten (59%) have respiratory complications of GERD. The initial procedures were as follows: One open Nissen fundoplication, two open Thal fundoplications, 13 laparoscopic Nissen fundoplications, and one laparoscopic Toupet fundoplication. The reoperative procedures performed were revision of fundoplication and hiatal hernia repair (13) or hiatal hernia repair only (four). Two patients had concurrent gastric emptying procedures. One procedure was converted to open for technical reasons. One patient developed a pelvic abscess secondary to leakage around the gastrostomy tube. One child had erosion into the esophagus of a Dacron patch that was used to close a large hiatal defect. Thirteen patients began feeding by the first postoperative day. We conclude that MIS techniques can be applied to reoperative surgery for the treatment of GERD with an acceptable complication rate in this difficult group of patients. Reoperative patients appear to have the same benefits from MIS as patients undergoing their initial procedure.     

Midface lifting as an adjunct procedure in ectropion repair

PURPOSE: To evaluate the efficacy of ectropion repair with adjunctive midface lift. METHODS: Retrospective chart review of patients with cicatricial, involutional, or paralytic ectropion with midface descent. Ectropion repair with adjunctive supraperiosteal midface lifting was performed on each patient. Surgical indications included lower eyelid ectropion, lagophthalmos, and/or cosmetic deformity. Outcomes analyzed were recurrence or adequacy of ectropion correction, complications, and need for further surgery. Surgical success was determined by the need for further surgery. RESULTS: A total of 32 procedures performed on 22 patients undergoing ectropion repair with adjunctive supraperiosteal midface lift were reviewed. Of the 15 procedures for patients with cicatricial ectropion, 80% (12 of 15 procedures) had improvement of lower eyelid position, without the need for further surgery; 71.4% of procedures for involutional ectropion (10 of 14 procedures) resulted in improvement in lower eyelid position, without the need for further surgery. There was improvement in ectropion in all patients with paralytic ectropion and no recurrences. A total of 5 patients had recurrences after ectropion repair with midface lift secondary to perioperative complications, a shortage of anterior lamella, or due to a heavy midface. CONCLUSIONS: We demonstrated that most patients undergoing midface lift in addition to ectropion repair have a favorable result. This is to be expected, given the close anatomic relationship between the lower eyelid and the midface. A midface lift should be considered in all patients who have both ectropion and significant midface descent.     

Flexor Tenosynovectomy for Recurrent Carpal Tunnel Syndrome: A Retrospective Case Series of 108 Hands

Background: The etiology of recurrent carpal tunnel syndrome (CTS) is unclear, and outcomes following secondary surgery in this demographic have been poorer than primary surgery. Fibrosis and hypertrophy have been identified in the flexor tenosynovium in these patients. The authors use flexor tenosynovectomy (FTS) for recurrent CTS after primary carpal tunnel release and present a review of these patients. Methods: A retrospective chart review was performed of 108 cases of FTS for recurrent CTS from 1995 to 2015 by 4 attending surgeons at one institution. Demographic information, symptoms, and outcomes were among the data recorded. A phone survey was conducted on available patients where the shortened version of the Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH) and satisfaction were assessed. Results: Average office follow-up was 12 months. Average age was 57.5 years. A total of 104 (96%) reported symptom improvement and 48 (44%) reported complete symptom resolution. Forty patients were available for long-term follow-up at an average 6.75 years postoperatively via phone interview. Average QuickDASH score was 31.2 in these patients. Thirty-six (90%) of 40 patients were initially satisfied at last office visit, and 31 (78%) of 40 were satisfied at average 6.9 years, a maintenance of satisfaction of 86%. Satisfied patients were older (58 years) than unsatisfied patients (51 years). Conclusion: Both long-term satisfaction and QuickDASH scores in our cohort are consistent with or better than published results from nerve-shielding procedures. The authors believe a decrease in both carpal tunnel volume and potential adhesions of fibrotic or inflammatory synovium contributes to the benefits of this procedure. This remains our procedure of choice for recurrent CTS.     

Perioperative considerations in patients with Gitelman syndrome: a case series

Study ObjectiveTo determine the perioperative considerations for low-risk and high-risk surgery in patients with Gitelman syndrome.DesignRetrospective chart review.SettingUniversity-affiliated medical center.Patients42 patients with Gitelman syndrome.MeasurementsOf the 42 patients with Gitelman syndrome, 5 underwent procedures requiring anesthesia: mastectomy, spinal fusion, thyroidectomy, tonsillectomy, and bronchoscopy. The anesthesia record and all associated laboratory tests and clinical notes associated with those procedures were recorded.Main ResultsNo acute electrolyte abnormalities or postoperative complications occurred with these procedures in patients with Gitelman syndrome.ConclusionGitelman syndrome is a mild disorder when appropriately managed.     

Lateral talar process fracture and peroneal tendon dislocation: a previously unrecognized injury complex

BACKGROUND: Lateral talar process fractures and peroneal tendon dislocations are frequently unrecognized at the time of injury. Lateral process fractures were initially classified by Hawkins as three types. Type II injuries are comminuted fractures involving both the talofibular and talocalcaneal articular surfaces. The purpose of this retrospective chart review was to describe an injury complex of Type II lateral talar process fracture with peroneal tendon dislocation. MATERIALS AND METHODS: Between January of 1995 and December 2006, 13 patients were seen for a lateral talar process fracture. Patients' charts were reviewed for fracture classification, mechanism of injury, radiographic studies, treatment, secondary procedures, length of followup and return to previous activity level. Concurrent peroneal tendon dislocations were identified in a subset of these patients. RESULTS: Thirteen patients were identified with lateral talar process fractures all of which were classified as a Hawkins Type II. Six patients (46%) had a simultaneous peroneal tendon dislocation. All patients underwent operative excision of the comminuted lateral process. Patients with the injury complex were more likely to undergo additional operative procedures, and were more likely to develop subtalar arthritis. At final followup, 71% of patients with isolated lateral process fractures and 33% of injury complex patients had returned to their previous level of activity CONCLUSION: An injury complex of Hawkins Type II lateral talar process fractures and peroneal tendon dislocation exists. Patients with comminuted lateral talar process fractures, especially those resulting from high-energy injuries, should be carefully evaluated for the possibility of concurrent peroneal tendon dislocation.     

Stroke during coronary bypass surgery: principal role of cerebral macroemboli.

OBJECTIVE: The purpose of this study was to gain insight into the etiology of stroke during coronary bypass surgery. METHODS: Retrospective review of prospectively gathered data on 6682 consecutive coronary bypass patients. Patients undergoing simultaneous procedures, including carotid endarterectomy, were excluded. We performed a systematic chart review of all patients who suffered a perioperative stroke. Predictors of stroke were determined with stepwise logistic regression analysis. RESULTS: The prevalence of stroke was 1.5% (n=98). Stroke patients had significantly increased intensive care unit and hospital length of stays, as well as increased mortality when compared to patients without stroke (all P< 0.001). Independent predictors of stroke were (in decreasing order of magnitude): age >70 years, left ventricular ejection fraction <40%, previous stroke or transient ischemic attack, normothermic cardiopulmonary bypass, diabetes, and peripheral vascular disease. Chart review revealed that the probable cause of stroke was macroemboli, likely from ascending aorta atherosclerosis, in 37% of patients and unknown in 38% of patients. Computerized tomography (CT) scans were obtained in 79 patients (81%). Lesions detected by CT were consistent with a macroembolic etiology: nearly all lesions were ischemic in nature and located in the distribution of major cerebral arteries, particularly the middle cerebral artery. CONCLUSIONS: Stroke is a devastating complication of coronary bypass surgery. Our multivariable risk factors for stroke, chart review, and CT findings all suggest that macroemboli, presumably from the ascending aorta, are the predominant cause of stroke during coronary bypass surgery. Future studies should be directed at minimizing the risk of embolization during cardiac surgery.     

The use of drains for outpatient orthopaedic surgeries: Safety and efficacy

While drains have been routinely used in orthopaedic surgery for postoperative wound drainage following inpatient surgical procedures, there are no published reports on the safety or efficacy of drains for outpatient orthopaedic surgeries. This review reports our experience between July 1995 and January 1996 with the use of drains for 35 patients having outpatient orthopaedic surgery. Consequences of drain usage were determined by medical chart review and a follow-up telephone survey in which patients were asked a series of questions regarding the drains used for their operation. None of the patients had an infection or any other medical problem as a result of drain usage and there were no problems with wound healing. Patients were quite capable of managing and removing their own drains. We conclude that drains are effective and can be used safely for outpatient orthopaedic surgical procedures.     

Use of ultrasound and surgery in adults with acute scrotal pain

Background: The epidemiology of patients with acute scrotal pain presenting to the emergency department (ED) is largely unknown. Urgent surgical referral is recommended for patients presenting with suspected testicular torsion. However, we have noted an increasing use of Doppler ultrasound (US) as an adjunctive tool in the evaluation of patients with acute scrotal pain. This study aimed to retrospectively review the presentation of patients with acute scrotal pain to a tertiary ED and the use of ultrasound in the assessment of acute scrotal pain. Methods: An explicit chart review was performed including all patients presenting to an adult tertiary ED between 2003 and 2008 with acute scrotal pain. The timing of presentation, initial assessment, review by the Urology team and the use of US were recorded. The diagnosis recorded at hospital discharge was the primary end point, while follow‐up at outpatient clinic or private urologist rooms was used as a secondary end point. Results: There were 329 patients with acute scrotal pain during the study period, with 294 patients included in the study. Of these, 173 (58.8%) had a US scan performed in the ED. There were 44 (15.0%) patients who underwent scrotal exploration, with 19 having a prior US. There was a significant increase in the use of US over the study period. Conclusions: Colour‐flow duplex Doppler ultrasonography appeared to play an increasing role in the assessment for patients presenting with acute testicular pain. Rapid and more reliable assessments of these patients may be possible through greater education of emergency personnel in ultrasonography techniques.     

Role of laparoscopy in identifying the clinical significance and cause of adhesions and chronic pelvic pain: a retrospective review at the Kiel School of Gynecological Endoscopy.

OBJECTIVES: We sought to define the role of laparoscopy in identifying the clinical significance, cause, and association between adhesions and chronic pelvic pain. METHODS: A retrospective chart review was conducted from October 2004 to July 2005, at the Kiel School of Gynecological Endoscopy, University Hospitals Schleswig-Holstein, Campus Kiel, Germany. Included in the study was the analysis of 462 laparoscopic procedures; 275 (59.5%) of the patients undergoing these procedures had pelvic or abdominal adhesions. Of these, 84 (30.5%) patients were admitted with the main complaint of chronic pelvic pain. Further evaluation and assessment of this group was carried out. RESULTS: Among those patients with adhesions, the second most frequent reason for admission was chronic pelvic pain (30.5%) (P<0.0005). In our study, adhesions were found in 79.2% (n=84) of patients (n=106) with chronic pelvic pain. These adhesions were thin-filmy (19.0%) or thick-fibrous (81.0%) adhesions containing blood vessels. Thick-fibrous adhesions were present in 50.0% of patients at multiple abdominopelvic sites (P<0.005). CONCLUSIONS: Thick-fibrous adhesions that extend beyond the pelvic sidewall can cause significant chronic abdominopelvic pain.     

Clinical experience with dexmedetomidine for implantation of deep brain stimulators in Parkinson's disease

The pharmacologic profile of the alpha-2 agonist dexmedetomidine (Dex) suggests that it may be an ideal sedative drug for deep brain stimulator (DBS) implantation. We performed a retrospective chart review of anesthesia records of patients who underwent DBS implantation from 2001 to 2004. In 2003, a clinical protocol with Dex sedation for DBS implantation was initiated. Demographic data, use of antihypertensive medication, and duration of mapping were compared between patients who received Dex (11 patients/13 procedures) and patients who did not receive any sedation (controls: 8 patients/9 procedures). There were no differences in severity of illness between the two groups. Dex provided patient comfort and surgical satisfaction with mapping in all cases, and significantly reduced the use of antihypertensive medication (54% in the Dex group, versus 100% in controls, P = 0.048). In DBS implantation, sedation with Dex did not interfere with electrophysiologic mapping, and provided hemodynamic stability and patient comfort. Routine use of Dex in these procedures may be indicated.     

Applications of Gore-Tex implants in rhinoplasty reexamined after 17 years

OBJECTIVE: To determine the efficacy of GORE-TEX (W. L. Gore & Associates Inc, Flagstaff, Arizona) alloplast in rhinoplasty. DESIGN: A 17-year retrospective medical chart review at a teaching hospital, community hospital, and private facial cosmetic surgery center. A total of 521 patients (122 male and 399 female; age range, 13-70 years) were followed for 12 months to 17 years. All patients had undergone GORE-TEX implantation rhinoplasty (685 implants in 158 primary procedures and 508 secondary procedures) performed by 1 surgeon. Patient satisfaction, expressed with respect to desired cosmetic benefit and functional outcome, and physician assessment, based on aesthetic improvement, technical considerations, and complications, were evaluated. Results were assessed according to the follow-up notes in the medical chart reflecting patients' and surgeon's comments and full preoperative and postoperative photographic documentation. RESULTS: GORE-TEX alloplasts, 1 to 10 mm thick, implanted in the nasal dorsum (n = 264), lateral nasal wall (n = 252), supratip dorsum (n = 85), and premaxilla (n = 84) showed excellent stability and tissue tolerance. Biological complications that required implant removal occurred in 1.9% of patients and included infection, soft tissue swelling, migration, and extrusion. CONCLUSIONS: With the exception of the nasal tip, columella, or problems in which corrections would require rigidity of the grafted or implanted material, the GORE-TEX alloplast is a safe, inexpensive, and predictable alternative to autografts. In the present series, more than 95% of implants used were 1 to 4 mm thick. In the remaining 5%, 6 implants ranged from 8 to 10 mm thick, and we found them acceptable. It is our opinion that for both primary and secondary rhinoplasty with adequate endonasal and external soft tissue coverage, GORE-TEX should be strongly considered for major and minor corrections of the nasal wall and bridge in properly selected patients.