Do pre‐irradiation dental extractions reduce the risk of osteoradionecrosis of the mandible?

BACKGROUND: This study was done to determine if pre-radiotherapy (pre-RT) dental extractions reduce the risk of osteoradionecrosis (ORN). METHODS: Between 1987 and 2004, 413 patients with oropharyngeal carcinomas were treated with definitive RT at the University of Florida. Dentate patients underwent pretreatment dental evaluation. Teeth in the RT field were usually extracted if thought to have poor long-term prognosis from dental disease. The endpoint was > or = grade 2 ORN using a modified staging system. Patients were excluded for local recurrence, additional RT above the clavicles, or head and neck surgery besides neck dissection. RESULTS: ORN rates were as follows: edentulous, <1%; teeth in-field with pre-RT extractions, 15%; and teeth in-field without pre-RT extractions, 9%. Patients with poor in-field teeth and pre-RT extractions had a higher 5-year incidence of ORN than those who did not have pre-RT extractions (16% vs 6%, p = .48). Likewise, for those with in-field teeth in good condition and pre-RT extractions, the 5-year ORN incidence was higher than for those who did not undergo extractions (15% vs 2%, p = .42). Multivariate analysis revealed increased ORN risk with doses of >70 Gy, once-daily fractionation, or brachytherapy. CONCLUSION: Pre-RT extractions do not appear to reduce the risk of ORN.     

Should the non‐operative management of appendicitis be the new standard of care?

Appendicitis is one of the most commonly encountered emergency presentations to the general surgical services. The operative management of this condition is associated with significant financial costs and represents a significant workload on the emergency surgical services. Negative appendicectomy rates remain high (20–25%) despite advancements in laboratory testing and imaging techniques. Recent data from randomized controlled trials suggests that non‐operative management in patients presenting with uncomplicated or non‐perforated acute appendicitis is a viable alternative, with only 23% of patients requiring an appendicectomy at 1 year and an overall reduction in complications. In view of this, the traditional teaching of mandatory appendicectomy for all patients with acute appendicitis should be challenged. This article briefly reviews the evidence that supports the use of diagnostic tests to reduce the negative appendicectomy rate and examines the potential selection criteria for non‐operative management. The data raises the questions: can a 20–25% negative appendicectomy rate be defended as best practice and can the traditional dogma of early appendicectomy to prevent perforation be supported?     

The Seventh Prototype of the Mini‐Spindle‐Pump: Does It Fulfill the Expectations of a Short‐Term Pump?

According to recent trends to develop implantable nonpulsatile blood pumps for different function modes and times, our intention was and still is to build a Mini-Spindle-Pump for a pumping duration of about 14 days. Initial conception for this plan was the premise that the device in a mock circuit should move 4 L of water/min at a speed of 12,000 to 15,000 rpm against a pressure difference of 90 mm Hg between pump inlet and outlet. Despite the development of 6 different prototypes, this project was not realized. Under the above-mentioned conditions, the main problem of this type of blood pump, the blood trauma, could not be reduced to an adequate level, i.e., the Mini-Spindle-Pump is not a high speed pump. Therefore, a revision of the conception was necessary. The device in a mock circuit should transport 5 L of water/min at a speed of about 9,000 rpm against a pressure difference of 90 mm Hg between its inlet and outlet. Considering the implantability of the blood pump, the following measurements for its components were arrived at. The U-shaped blockformed plexiglas housing was enlarged to 120 x 40 x 40 mm (length of blood chamber 86 mm, inner diameter 27 mm), and the rotor with 5 windings was redesigned at a length of 64 mm (outer diameter 25 mm, inner diameter 6.7 mm). In a mock circuit, this 7th prototype transported with a speed of 9,000 rpm about 10 L of water/min at an afterload of 80 mm Hg. In acute animal experiments with calves up to 15 h of pumping duration, the device showed the expected efficiency. Experiments with a longer pumping duration are necessary to confirm that this prototype will fulfill the criteria of a short-term pump according to Dr. Y. Nosé's advice.     

Twenty-Five Years of Cancer Follow-Up; Is the Data Worth the Effort?

Annals of Surgical Oncology - Substantial resources are dedicated to long-term follow-up within cancer registries; however, the completeness of these data is poorly characterized. Our objectives...     

What is the Future of Surgical Treatment of Obesity; What Will be the Place of the American Society for Bariatric Surgery?

There is focused awareness of severe obesity, its health risk and possible solutions. Yet there remains confusion and skepticism among the medical profession over therapeutic action. Basic questions unanswered project futility toward solving the problem, while the general public is driven toward unsound solutions which are costly. A cloud of cynicism pervades for those seeking to control this problem surgically. The problem will persist. Its health risks increasingly will demand attention, and solution will be sought by surgical means which is the only control for comorbidity, but does not cure severe obesity. Pressure to totally control excess weight results in undesirable sideeffects. Careful judgement must be used. New insight is desperately needed to understand severe obesity, its etiology and pathophysiology. This insight is likely to come from careful observations of those engaged in its control. Surgical control, profound in its success, provides a model that should lead to more complete understanding of severe obesity, as in the example of “Burns-The Universal Trauma Model.” Those experienced and engaged in this work show courage in this orphan field of endeavour. They lead the way as general surgeons and gastrointestinal surgeons with broad application of knowledge for this model. This society will continue to focus the expertise and the opportunities in this area. The future predicted is exciting and demanding.     

Stiffness measurement of the neocallus with the Fraktometer FM 100<Superscript>®</Superscript>

Introduction: The assessment of fracture healing is subjective, and neither radiology nor manual examination allows a reliable determination of bone healing. Fracture healing control in the treatment of tibia shaft fracture with external fixator by a stiffness measurement system (Fraktometer FM 100^®) is known from clinical studies. The purpose of this study was to follow stiffness control at external fixator in healing of callotasis with the stiffness measurement system. Materials and methods: From 1994 to 1997 stiffness measurements with the described system (Fraktometer FM 100) were performed in the BG-Clinic Ludwigshafen to assess the healing course in 11 cases of callotasis at lower limb. Results: In ten cases, regular healing could be followed by signal decrease; in one case, a persistent signal without tendency to decrease was able to reveal callotasis failure at an early point of time. The investigation could also show the importance of bending stiffness control. One case of late axis deformation after fixator removal occurred because of disregarding delayed bending signal decrease. Conclusion: Measurements of the external fixator’s stiffness after callotasis can provide useful additional information for further treatment strategy.     

What is the role of risk‐adjusted funnel plots in the analysis of radical cystectomy volume–outcome relationships?

Study Type – Therapy (outcomes research) Level of Evidence 2b What’s known on the subject? and What does the study add? The use of funnel plots has helped to overcome the limitations and risks of ranking surgical performance. The case for a more widespread application of funnel plots in assessing and reporting performance in surgery has been made. No study has previously published a funnel plot analysis of outcomes for radical cystectomy in England. No Trust, using the final complex model for risk‐adjustment, can be confidently said to have a performance worse than the national average for both mortality and re‐intervention rates following radical cystectomy. Funnel plots act as a complementary method of validating volume‐outcome data by displaying disaggregated outcomes at a provider level and reduce the opportunity for spurious labelling of outliers.

OBJECTIVE

? To explore whether risk‐adjusted funnel plots are a useful adjunct to analyse volume–outcome data and to further facilitate our understanding of institutional performance data by combining funnel‐plot methodology with an incremental statistical modelling approach.

PATIENTS AND METHODS

? Risk‐adjusted funnel plots were generated for mortality and re‐intervention rates after elective radical cystectomy using administrative data from NHS Hospital Trusts between 2000/01 and 2006/07. Trusts were divided into volume tertiles based on their average annual cystectomy rate. ? A funnel plot was produced for each of the following four incremental statistical models: model one (no adjustment), model two (adjusted for patient case mix variables), model three (case mix and ‘clustering’ of patients) and model four (additional adjustment for institutional structural and process‐of‐care variables).

RESULTS

? In the final complex model (model four), no Trusts had abnormally high mortality or re‐intervention rates. ? Comparison of the funnel plots showed the importance of adjusting for certain confounding factors, such as the surgeon, at the institutional level, before they could be labelled as having truly outlying performance.

CONCLUSION

? Risk‐adjusted funnel plots have a useful role to play as a component of a methodological framework for investigating the volume–outcome relationship at the institutional level. They can act as a complementary method of validating data by displaying disaggregated outcomes at provider level and account for unmeasured confounders, so reducing the opportunity for spurious labelling of outliers.     

Does the cleaning technique influence the durability of the <9F flexible ureteroscope?

BACKGROUND AND PURPOSE: The fragility of the <9F flexible ureteroscope limits its availability to general urology practice. The purpose of this study was to determine whether the technique used to clean the flexible ureteroscope or the number of persons handling the instrument during the cleaning process influenced endoscope breakage or deterioration during regular endourologic use. PATIENTS AND METHODS: A new Olympus URF/P3 flexible 7.5F ureteroscope was used for each of two 30-day study periods during which a single surgeon used the endoscope for a variety of upper urinary tract procedures. During the first 30-day period (Group 1), the endoscope was leak-proof-pressure tested and cleaned by the endourology support team using the Steris 20 (peroxyacetic acid 35%) technique. During the second 30-day period (Group 2), the endoscope was leak-proof tested and cleaned only by the surgeon using the Cidex (glutaraldehyde 2.4%) technique. A record was kept for each ureteroscopic case to document the patient position, access technique, time the endoscope was in the urinary tract, instruments passed through the ureteroscope, and the maximum irrigant pressure used. In addition, a record was made of the number of broken fibers, the degree of flexion and deflexion of the endoscope, and the problems encountered with the endoscope during the case. RESULTS: The two study groups were similar in terms of the total number of cases performed, the mean time the endoscope was in the urinary tract per case, the access approach used, and the use of the ureteral access sheath and ancillary equipment. In Group 2, the endoscope was used for a longer total time (618 minutes v 457 minutes), and access to a lower pole calix was more than twice as common as in Group 1. This may explain why more broken fibers were noted in the instrument used in Group 2 over the study period (eight v four broken fibers) than in Group 1. The only breakage occurred as a result of the surgeon accidentally activating the laser probe inside the working channel of the endoscope in Group 2. CONCLUSION: The technique and number of personnel involved in the maintenance and cleaning of the flexible ureteroscope does not have a significant effect on the durability and function of these instruments. It is the arduous demands of the endourologic procedure that influence the durability of these fragile endoscopes.