Experience with two different techniques of percutaneous dilational tracheostomy in 54 neurosurgical patients

We report 54 patients with critical neurosurgical diseases (16 females, 38 males, age 21–84 years, mean 63.2 years) who were treated with bedside percutaneous dilational tracheostomy (PDT) because of respiratory insufficiency due to their cerebral disease. Bronchoscopically guided PDT was performed after stabilisation of the acute stage of neurosurgical disease. In 15 cases, Ciaglia's multiple dilation technique was used, and in 39 patients the dilational forceps technique according to Griggs was performed. In 14 cases (five Ciaglia's method, nine Griggs technique), intracranial pressure (ICP) was monitored throughout the procedure. Fifty-two procedures were completed. In two cases, PDT had to be aborted because of inability to puncture the trachea. No death occurred. There was a total complication rate of 16.7%, including the aborted procedures, with 3.7% of the complications classified as severe. No increase in ICP was noted. We conclude that bedside PDT, especially with the Griggs system, is safe and effective if done under bronchoscopic control. With the standard narcotic regimen used in our patients, no increase in ICP occurred.     

Experience with two different techniques of percutaneous dilational tracheostomy in 54 neurosurgical patients

We report 54 patients with critical neurosurgical diseases (16 females, 38 males, age 21-84 years, mean 63.2 years) who were treated with bedside percutaneous dilational tracheostomy (PDT) because of respiratory insufficiency due to their cerebral disease. Bronchoscopically guided PDT was performed after stabilisation of the acute stage of neurosurgical disease. In 15 cases, Ciaglia's multiple dilation technique was used, and in 39 patients the dilational forceps technique according to Griggs was performed. In 14 cases (five Ciaglia's method, nine Griggs technique), intracranial pressure (ICP) was monitored throughout the procedure. Fifty-two procedures were completed. In two cases, PDT had to be aborted because of inability to puncture the trachea. No death occurred. There was a total complication rate of 16.7%, including the aborted procedures, with 3.7% of the complications classified as severe. No increase in ICP was noted. We conclude that bedside PDT, especially with the Griggs system, is safe and effective if done under bronchoscopic control. With the standard narcotic regimen used in our patients, no increase in ICP occurred.     

经皮气管切开术在神经外科病人中的应用

目的 介绍经皮气管切开术在神经外科的应用经验。方法 对42例神经外科病人采用导丝扩张钳法行经皮气管切开术。结果 41例成功，1例改行正规的气管切开术。手术时间平均8．5min。无严重并发症及与手术操作有关的死亡发生。结论 经皮气管切开术简单、快速、损伤小，可在神经外科广泛应用。     

Changes in grip strength in a randomized study of carpal tunnel release by three different techniques

Carpal tunnel release is frequently followed by weak grasp but recently, endoscopy has been claimed to avoid this pitfall. 277 patients representing 303 CT were enrolled in a prospective randomized study to assess changes in grasp after classical open CTR (Group I - 77 cases), ligamentoplasty (Group II - 133 cases) and an Agee endoscopic CTR (Group III - 99 cases). Grasp was measured pre-operatively and post-operatively every month for six months to analyse strength recovery according to technique, dominance, sex, motor conduction velocity, job, and leisure activity.There were no complications in the series except one RSD and six open conversions in the Agee group due to technical problems.Pre-operative CT was accompanied by an average loss of strength of 18%. In the postoperative period, the contralateral side had an increase in strength from 2% to 12.5%. These data plus the frequent bilaterality of CT explained the bias of any post-operative study without pre-operative measurement.Strength recovered faster and better in Group II and III. At three months, the percentage of patients having recovered was 38% in Group I, 54% in Group II, 58% in Group III. An explanation of similarity in the last two groups could be found in the modification of Agee procedure preserving an intermediate fascia, avoiding full separation of the two edges of the ligament, as in the ligamentoplasty.     

Early tracheostomy decreases ventilation time but has no impact on mortality of intensive care patients: a randomized study

Background

Long-term ventilation in intensive care units (ICUs) is associated with several problems such as increased mortality, increased rates of ventilator-associated pneumonia (VAP), and prolonged time of hospitalization, and thus leads to enormous healthcare expenditure. While the influence of tracheostomy on VAP incidence, duration of ventilation, and time of hospitalization has already been analyzed in several studies, the timing of the tracheostomy procedure on patient’s mortality is still controversial. The aim of our study was to investigate whether early tracheostomy improved outcome in critically ill patients.

Materials and methods

Within 2?years, 100 critically ill, predominantly surgical patients entered this prospective randomized study. A percutaneous dilatational tracheostomy was performed either early (≤4?days, 2.8?days median) or late (≥6?days, 8.1?days median) after intubation.

Results

We could demonstrate that mortality was not significantly reduced in the early tracheostomy (ET) group in contrast to the late tracheostomy (LT) group. ET was associated with decreased VAP incidence (ET 38% vs. LT 64%), decreased duration of ventilation (ET 367.5?h vs LT 507.5?h), and shorter time of hospitalization both in hospital (ET 31.5?days vs LT 68?days) and in ICU (ET 21.5?days vs LT 27?days).

Conclusion

Despite many advantages like reduced time of ventilation and hospitalization, early tracheostomy is not associated with decreased mortality in critically ill patients.     

Improved patency in vein grafts harvested with surrounding tissue: results of a randomized study using three harvesting techniques

BACKGROUND: The technique of harvesting the saphenous vein for coronary artery bypass grafting influences the fate of vein grafts. The patency rate of a novel "no-touch" technique in which the vein is harvested with a pedicle of surrounding tissue and not distended was compared with two other techniques. METHODS: One hundred fifty-six patients who underwent coronary artery bypass grafting were randomized to three saphenous vein harvesting groups: group C (conventional)--the vein was stripped, distended, and stored in saline; group I (intermediate)--the vein was stripped, local application of papaverine was used instead of distention, and the vessel was then stored in heparinized blood; and group NT (no-touch)--the vein was harvested with surrounding tissue, not distended, and stored in heparinized blood. Surgical and clinical factors that might influence graft occlusion were recorded. One hundred twenty-seven vein grafts in group C, 116 in group I, and 124 in group NT, as well as 118 left internal mammary artery grafts, were angiographically assessed at 18 months mean follow-up time. RESULTS: The vein graft patency was 88.9% in group C, 86.2% in group I, and 95.4% in group NT. There was a statistically significant difference between the patency of the single-vein grafts in NT and the other two groups (p = 0.025). The higher the flow, the better the patency irrespective of the technique used. A higher attrition rate was found in vein segments taken from the knee area in group I. Poor vein quality affected patency in all groups. Forty-seven of all 51 sequential grafts (92.2%) were patent. The patency of left internal mammary artery grafts was 108 of 118 (91.5%). CONCLUSIONS: We conclude that preservation of the surrounding tissue of the saphenous vein using this no-touch technique abolishes venospasm intraoperatively and plays an important role in maintaining vein graft function and patency.     

Percutaneous versus surgical tracheostomy: a double-blind randomized trial

OBJECTIVE: To compare surgical (SgT) and percutaneous (PcT) tracheostomies. BACKGROUND: Percutaneous tracheostomy has been said to provide numerous advantages over classical SgT. METHODS: A prospective randomized trial with a double-blind evaluation was used to compare SgT and PcT. SgT and PcT were performed according to established techniques (n = 70). The procedure was performed at the bedside in the intensive care unit in 21 cases (30%). The outcome measures were divided into procedure-related variables, perioperative complications, and postoperative complications. The procedure-related variables (location, duration, and difficulty) were evaluated by the surgeon. The perioperative and postoperative complications were divided into serious, intermediate, and minor. Perioperative and early postoperative (14 days) complications were evaluated daily by an intensive care unit nurse blinded to the technique used. Long-term postoperative complications were evaluated 3 months after decannulation by a surgeon blinded to the surgical technique. RESULTS: There were no major complications in either group. Most variables studied were not statistically different between the PcT and SgT groups. The only variables to reach statistical significance were the size of the incision (smaller with PcT, p < 0.0001), minor perioperative complications (greater with PcT, p = 0.02), and difficult cannula changes (greater with PcT; p < 0.05). Among nonsignificant differences, difficult procedures and false passages were more frequent with PcT, whereas long-term unesthetic scars were more frequent with SgT. CONCLUSIONS: Both techniques are associated with a low rate of serious or intermediate complications when performed by experienced surgeons. There were more minor perioperative complications with PcT and more minor long term complications with SgT.     

Prevention of primary wound infection in neurosurgical patients: a 10-year study

Two neurosurgeons in private practice at three community hospitals followed a regimen of antimicrobial prophylaxis for 10 years. No primary wound infection occurred in a series of 2000 consecutive major operations. The study gives rise to certain recommendations for the prevention of postoperative sepsis in neurosurgical patients.     

Digital evaluation of the muscle functions of the lower extremities among inguinal hernia patients treated using three different surgical techniques: a prospective randomized study

Purpose  

An inguinal hernia is a common pathology that can be treated using several different surgical procedures. Although there have been many studies comparing the clinical results of these techniques, there has so far been no digital analysis of the alterations developing secondary to pain with regard to the muscle functions of the lower extremities. This prospective randomized trial was designed to compare this aspect for subjects treated using the laparoscopic techniques and those treated using the conventional method.     

Staple-line reinforcement during laparoscopic sleeve gastrectomy using three different techniques: a randomized trial

Background

The main drawback of laparoscopic sleeve gastrectomy (LSG) is the severity of postoperative complications. Staple line reinforcement (SLR) is strongly advocated. The purpose of this study was to compare prospectively and randomly three different techniques of SLR during LSG.

Methods

From April 2010 to April 2011, patients submitted to LSG were randomly selected for the following three different techniques of SLR: oversewing (group A); buttressed transection with a polyglycolide acid and trimethylene carbonate (group B); and staple-line roofing with a gelatin fibrin matrix (group C). Primary endpoints were reinforcement operative time, incidence of postoperative staple-line bleeding, and leaks. Operative time was calculated as follows: oversewing time in group A; positioning of polyglycolide acid and trimethylene carbonate over the stapler in group B; and roofing of the entire staple line in group C.

Results

A total of 120 patients were enrolled in the study (82 women and 38 men). Mean age was 44.6?±?9.2 (range, 28–64)?years. Mean preoperative body mass index was 47.2?±?6.6 (range, 40–66)?kg/m2. Mean time for SLR was longer in group A (14.2?±?4.2 (range, 8–18)?minutes) compared with group B (2.4?±?1.8 (range, 1–4)?minutes) and group C (4.4?±?1.6 (range, 3–6) minutes; P?Conclusions SLR with either polyglycolide acid with trimethylene carbonate or gelatin fibrin matrix is faster compared with oversewing. No significant differences were observed regarding postoperative staple-line complications.     

Safety of percutaneous tracheostomy in obese critically ill patients: a prospective cohort study

Obesity has been described as a relative contraindication for percutaneous tracheostomy. The objective of our study was to examine the safety and complications of percutaneous tracheostomy in obese patients. We conducted a prospective cohort study of all consecutive patients who underwent percutaneous tracheostomy at a tertiary medical-surgical intensive care unit between May 2004 and October 2005. We compared percutaneous tracheostomy in obese patients (body mass index > or = 30 kg/m2) to non-obese patients. We documented the occurrence of the following complications: aborting the procedure, accidental extubation, conversion to surgical tracheostomy, paratracheal placement, the development of pneumothorax, major bleeding (requiring blood product transfusion or surgical intervention) or death. We also documented hypoxia, minor bleeding (requiring pressure dressing or suturing), subcutaneous emphysema and transient hypotension. During the study period, 227 percutaneous tracheostomies were performed. There were 50 percutaneous tracheostomies in the obese group and 177 in the non-obese group. In 45 obese patients, percutaneous tracheostomy was performed without bronchoscopic guidance. Major complications were significantly higher in obese patients (12% vs. 2%, P = 0.04), while the rate of minor complications was not significantly different between the two groups. There were no instances of death or pneumothorax, subcutaneous emphysema or need for surgical intervention during or in the postoperative period in either group. Our study suggests that percutaneous tracheostomy can be performed safely in the majority of obese patients.     

Microsurgical vasoepididymostomy: a prospective randomized study of 3 intussusception techniques in rats

PURPOSE: Vasoepididymostomy is a technically challenging but cost-effective treatment for obstructive azoospermia. We evaluated the outcomes of 3 intussusception vasoepididymostomy techniques, namely 3 suture triangulation, 2 suture transverse and a new 2 suture longitudinal technique. MATERIALS AND METHODS: Male Wistar rats were randomized into 4 experimental and 1 control groups. After 3 weeks of vasal obstruction bilateral vasoepididymostomy was performed. In group I, 3 sutures were placed in triangular fashion. In group II, 2 sutures were placed perpendicular to the tubule. In group III, 2 sutures were placed longitudinal to the tubule. The tubules were then opened in the direction of the needles and anastomosed to the vasa. After 5 months patency was evaluated in blinded fashion. RESULTS: The functional patency rate (presence of motile sperm in the vas) was 64%, 64% and 93% in groups I to III, respectively (p <0.001). As evaluated by methylene blue retrograde vasography toward the epididymis, the mechanical patency rate was similar for the 3 techniques, that is 86%, 86% and 93% in groups I to III, respectively. The sperm granuloma rate was significantly lower in group III (36%, 21% and 0% in groups I to III, respectively, p <0.001). CONCLUSIONS: Transverse 2 suture vasoepididymostomy has a patency rate similar to that of the 3 suture technique. Our new 2 suture longitudinal technique, which allows a larger opening in the epididymal tubule for anastomosis, is superior to the 2 and 3 suture techniques with respect to the patency and sperm granuloma rates.