Hemorrhagic vascular complications of endoscopic transsphenoidal surgery.

Two hundred and fifty consecutive patients operated on by an endoscopic endonasal transsphenoidal approach were retrospectively analyzed in order to evaluate hemorrhagic vascular complications occurring during or after the surgical procedure and their appropriate management. Vascular complications of endoscopic transsphenoidal surgery are identical to those of a microsurgical transsphenoidal approach. Damage to the sphenopalatine artery and to the internal carotid artery (ICA), which are the most frequent vascular troubles, may require technical tricks because of some aspects connected to the approach itself and of the physical properties of the endoscope. Furthermore, the progress in interventional neuroradiology in the last decades offers new solutions in respect to the past, where the use of the surgical microscope was already a tremendous progress. The anatomic substrate of each complication is discussed, along with the peculiar surgical details related to it.     

初次全膝关节置换术后并发症及翻修手术的原因分析

目的 探讨初次全膝关节置换术后30 d内相关并发症发生情况及翻修手术的相关因素.方法 收集2001年1月至2012年12月在北京协和医院骨科进行初次全膝关节置换术患者的临床资料,假体均为固定平台假体,采用骨水泥固定,排除翻修病例及血友病关节炎患者.共有1 920例患者(2 779例次全膝关节置换手术)纳入研究,男性323例,女性1 607例;年龄25～86岁,平均(66±9)岁.骨关节炎1 720例(89.58％),类风湿关节炎168例(8.75％),强直性脊柱炎12例(0.63％),继发骨关节炎20例(1.04％).随访患者术后30 d内发生的主要系统并发症、局部并发症及发生的翻修手术及相关因素.结果 随访截至2013年12月,共有1 854例患者(2 693个关节)获得随访,失访率为3.44％.术后平均随访67个月,死亡3例.41例(2.21％)患者出现系统并发症,其中最常见的为呼吸系统并发症(0.49％,9/1 854)及心血管并发症(0.38％,7/1 854).术后经超声证实的症状性深静脉血栓形成发生率为3.02％ (56/1 854),其中7例发生肺栓塞.术后发生局部并发症24例(1.29％),包括伤口愈合不良、伤口感染、神经损伤.59个关节接受翻修手术治疗,常见原因包括感染后松动(1.19％,32/2 693)和术后关节僵硬(0.37％,10/2693).结论 初次全膝关节置换术后30 d内最常见系统并发症为呼吸系统及心血管系统并发症.感染后松动是术后翻修最常见的原因.     

Surgical complications after transsphenoidal microscopic and endoscopic surgery for pituitary adenoma: a consecutive series of 506 procedures

Background

This single-institution, consecutive series of transsphenoidal procedures included all patients in a defined population of 2.6 million inhabitants who underwent surgery during a specific time period.

Objective

We sought to determine the surgical complication rate and overall survival rate after transsphenoidal surgery for pituitary adenoma.

Methods

All transsphenoidal procedures for histologically verified pituitary adenomas performed between September 2002 and February 2011 at our institution were included in this study. The data were obtained from a prospectively collected database and from reviewing medical records. No patients were lost to follow-up, and the median follow-up time was 28 months.

Results

A total of 506 transsphenoidal procedures were performed on 446 patients. There were 268 microscopic and 238 endoscopic procedures involving 352 non-functioning and 154 hormone-secreting adenomas. A total of 73 % of the procedures were primary surgeries, and 27 % were repeat surgeries for tumor recurrence. The overall complication rate was 9.1 %. The three most frequent complications were cerebrospinal fluid (CSF) leakage (4.7 %), meningitis (2 %), and visual deterioration (2 %). Multivariate analyses showed that the overall risk for complications increased with older age, surgery for recurrent tumors, and surgery performed by a low-volume surgeon. There was no significant difference in the overall complication rate between the microsurgical and endoscopic techniques. The rate of surgical mortality was 0.6 %, and the overall survival rates at 1 and 5 years were 95 % and 90 %, respectively. The only negative predictor of survival was older age.

Conclusions

Transsphenoidal surgery for pituitary adenomas has a low complication rate and a low rate of mortality. We did not find a significant difference in the complication rate between endoscopic and microscopic techniques.     

Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas

OBJECT: To assess postoperative complications related to the surgical procedure, a retrospective analysis was conducted in a series of 146 consecutively treated patients who underwent an endoscopic endonasal transsphenoidal approach to the sellar region for resection of pituitary adenomas between January 1997 and July 2001. METHODS: Complications were divided into groups (nasofacial, sphenoid sinus, sella turcica, supra or parasellar, and endocrine complications) according to the anatomical structures and the systems involved. Overall, a decreased incidence of complications has been observed, compared with large historical series of the traditional microsurgical transsphenoidal approach, likely because of the overview inside the anatomy facilitated by the endoscope, and the decreased surgical trauma. CONCLUSIONS: Transsphenoidal surgery, either microscopic or endoscopic, is a safe procedure in experienced hands, but serious complications still occur and must be reduced as much as possible. Additional improvement can be expected with greater experience and new technical developments. A coordinated team effort with other dedicated colleagues from different specialties is advised.     

Comparative in-hospital morbidity and mortality after revision versus primary thoracic and lumbar spine fusion

Background context

Despite increasing utilization of surgical spine fusions, a paucity of literature addressing perioperative complications after revision posterior spinal fusion (RPSF) versus primary posterior spine fusion (PPSF) of the thoracic and lumbar spine exists.

Purpose

To examine demographics of patients undergoing PPSF and RPSF of the thoracic and lumbar spine, assess the incidence of perioperative morbidity and mortality, and determine independent risk factors for in-hospital death.

Study design/setting

Analysis of nationally representative data collected for the National Inpatient Sample (NIS).

Patient sample

All discharges included in the NIS with a procedure code for posterior thoracic and lumbar spine fusion from 1998 to 2006.

Outcome measures

In-hospital mortality and morbidity.

Methods

Data collected for each year between 1998 and 2006 for the NIS were analyzed. Discharges with a procedure code for thoracic and lumbar spine fusion were included in the sample. The prevalence of patient- as well as health care–related demographics was evaluated by procedure type (primary vs. revision). Frequencies of procedure-related complications and in-hospital mortality were analyzed. Independent predictors for in-hospital mortality were determined.

Results

We identified 222,549 PPSF and 12,474 RPSF discharges between 1998 and 2006. Patients undergoing PPSF were significantly younger (51.23 years; confidence interval [CI]=51.16, 51.31) and had lower average comorbidity indices (0.40; CI=0.39, 0.41) than those undergoing RPSF (52.69 years; CI=52.43, 52.97) and (0.44; CI=0.43, 0.45), p<.0001. The incidence of procedure-related complications was 16.02% among RPSF compared with 13.44% in PPSF patients (p<.0001). In-hospital mortality rates after PPSF were approximately twice those of RPSF (0.28% vs. 0.15%, p=.006). Adjusted risk factors for increased in-hospital mortality included PPSF compared with RPSF, male gender, and increasing age. A number of comorbidities, complications, and specific surgical indications increased the risk for perioperative death.

Conclusion

Despite being performed in generally younger and healthier patients and having lower perioperative morbidity, PPSF procedures are associated with increased mortality compared with RPSF procedures. The findings of this study can be used for risk stratification, accurate patient consultation, and hypothesis formation for future research.     

Prognosis of complications after reconstructive surgeries on the aorto-iliac segment

Evaluation of efficacy of neuronet technologies for prognosis of specific complications after reconstructive surgeries on aorto-iliac segment was made. A learning sample consisted of 500 reconstructive surgeries, a test one - 161. High efficacy of analog neuron nets was revealed. Prognosis of early thrombosis, postoperative bleeding and also of lethal outcome demonstrated better results, mistake of prognosis was 3.7, 1.2 and 4.6%, respectively. Prognosis of infectious complications and long-term outcomes demonstrated worse results, mistake of prognosis was 7.0 and 10.5%, respectively.     

发育性髋关节脱位术后再脱位的原因分析与翻修策略

[目的]分析手术治疗发育性髋关节脱位术后再脱位的原因,探讨减少和避免再脱位的对策。[方法]2011年7月～2015年7月,本院经手术治疗发育性髋关节脱位术后再脱位患儿31例(31髋),男9例,女22例,初次手术年龄20个月～10岁1个月,平均(31.21±10.33)个月。对所有患儿进行3D CT影像检查,综合分析再脱位原因。针对具体病理进行翻修术,包括切开复位Salter截骨16髋,其中同时行股骨短缩手术者12髋;切开复位加Pemberton截骨13髋,其中同时行股骨短缩手术者11髋;切开复位加Chiari截骨者2髋。对翻修手术的效果进行临床与影像分析。[结果]再脱位原因包括:11髋内收肌紧张,8髋髂腰肌未切断,7髋关节囊内盂唇内翻,6髋内侧关节囊未彻底松解,11髋臼底脂肪纤维组织填充;10髋髋臼指数45°,2髋后方骨质缺损。13髋股骨头缺血性坏死,4髋严重变形伴短颈,5髋颈干角160°,7髋股骨颈前倾角40°。31例(31髋)再手术复位成功率100%。随访25～72个月,平均(35.33±11.24)个月,末次随访时根据Mckay临床评估标准,优25髋,良4髋,可2髋,优良率93.55%。影像检查显示中心性复位29例,残留髋臼发育不良1例,新发生股骨头坏死1例。[结论]手术治疗发育性髋关节脱位术后再脱位的主要原因包括:术中关节囊及周围软组织处理不当、手术指征及术式掌握不当、手术操作不规范及年龄等因素。只有遵循个体化的治疗原则,获得术中股骨头与髋臼稳定的同心圆复位,才能避免再次脱位的发生。     

Incidence and predictors of early complications following primary and revision total ankle arthroplasty

BackgroundTotal ankle arthroplasty (TAA) offers an effective option for end-stage osteoarthritis. The incidence and preoperative risk factors for early adverse events (AEs) following primary and revision TAA may be useful information for providers.MethodsA large database was queried from 2010 to 2016 to identify 905 patients of whom 818 underwent primary TAA (90.4%) and 87 underwent revision TAA (9.6%). Data on patient demographics, comorbidities, and hospital length of stay were analyzed as risk factors for reported 30-day AEs.ResultsThe overall AE rate was 5.5% (50/905) for the entire cohort. AEs occurred more frequently for revision TAA (9/87) than primary TAA (41/818) cases (OR 2.43, p = 0.022). Age (OR 1.03, p = 0.045), BMI (OR 1.04, p = 0.046), and revision TAA (OR 2.56, p = 0.002) were independent risk factors for 30-day AEs in multivariate analysis.ConclusionsOlder age, higher BMI, and revision cases are associated with a higher risk of AEs.     

Sellar repair with fibrin sealant and collagen fleece after endoscopic endonasal transsphenoidal surgery

OBJECTIVE: To determine, in patients undergoing sellar repair after endoscopic endonasal transsphenoidal surgery, the clinical efficacy of a combination of fibrin sealant/collagen fleece compared to the use of fibrin sealant or collagen fleece alone, in preventing CSF-related (cerebrospinal fluid) postoperative complications. METHODS: From a retrospective analysis of our series of 242 consecutive endoscopic transsphenoidal procedures, in 56 out of the 90 cases in which the sella had been repaired, fibrin sealant and/or collagen fleece was employed, both in combination with one or multiple layers of other materials. The incidence of postoperative CSF leaks and the need for a postoperative lumbar drainage in the groups of fibrin sealant or collagen fleece treated patients were compared to the group of patients treated with the fibrin sealant/collagen fleece combination. RESULTS: In 2 out of 16 fibrin sealant treated patients a postoperative CSF leak presented, and in 6 out of these 16 subjects a postoperative lumbar drainage was necessary; patients who received a fibrin sealant/collagen fleece combination exhibited no detectable postoperative CSF leak, and no postoperative lumbar drainage was used. CONCLUSIONS: Closure of the sella turcica with fibrin sealant in combination with a collagen fleece is a safe and effective method to prevent CSF fistulas. When used in combination, the collagen fleece enhances the sealing and tissue regeneration properties of the fibrin sealant, thus reducing the incidence of postoperative CSF leaks, obviating the need for a lumbar drain placement.     

内镜下乳头肌切开术后并发症的外科治疗

目的 探讨内镜下乳头肌切开术（EST）后严重并发症的外科治疗。方法 收治11例EST术后并发严重出血、穿孔、胰腺炎患者，其中单纯出血4例，单纯穿孔3例，穿孔伴出血3例，穿孔伴重症胰腺炎1例。结果 单纯出血4例，单纯穿孔3例，穿孔伴出血1例患者均存活，穿孔伴出血2例及1例穿孔伴重症胰腺炎患者死亡。结论 早期诊断，积极手术是降低病死率的关键。对穿孔伴出血或重症胰腺炎的患者，强调充分引流胆汁、胰液、建立通畅的腹腔引流。     

EST严重并发症的外科治疗

目的探讨EST术后严重并发症的外科治疗。方法收治14例EST术后并发严重出血、穿孔、胰腺炎病人。其中单纯出血5例，单纯穿孔5例，穿孔伴出血3例，穿孔伴重症胰腺炎1例。结果单纯出血4例、单纯穿孔5例、穿孔伴出血2例病人存活。单纯出血1例、穿孔伴出血2例及穿孔伴重症胰腺炎1例病人死亡。结论早期诊断，积极手术是降低死亡率的关键。对穿孔伴出血或胰腺炎的病人，为减少胆汁、胰液对EST切口的刺激，应建立通畅的腹腔引流。     

Early patient outcomes after primary and revision total knee arthroplasty. A prospective study

There has been speculation as to how the outcome of revision total knee arthroplasty (TKA) compares with that of primary TKA. We have collected data prospectively from patients operated on by one surgeon using one prosthesis in each group. One hundred patients underwent primary TKA and 60 revision TKA. They completed SF-12 and WOMAC questionnaires before and at six and 12 months after operation. The improvements in the SF-12 physical scores and WOMAC pain, stiffness and function scores in both primary and revision TKA patients were highly statistically significant at six months. There was no statistically significant difference in the size of the improvement in the SF-12 physical and WOMAC pain, stiffness and function scores between the primary and revision patients at six months after surgery. The SF-12 mental scores of patients in both groups showed no statistically significant difference after surgery at the six- and 12-month assessments. Our findings show that primary and revision TKA lead to a comparable improvement in patient-perceived outcomes of physical variables in both generic and disease-specific health measures at follow-up at one year.     

内镜下大隐静脉交通支离断术术后并发症防治

目的探讨内镜下大隐静脉交通支离断术术后并发症的防治方法。方法回顾分析我院2002年1月至2005年12月收治下肢慢性静脉功能不全患者136例临床资料,共172条肢体均行内镜下大隐静脉交通支离断术(subfascialendoscopicperforatorsurgery,SEPS),155条肢体随访,随访率90.1%,随访时间1~36个月。结果SEPS术后出现筋膜下出血12条肢体(7.1%),皮下气肿18条肢体(10.5%),小腿前内侧及足踝区感觉麻木33条肢体(19.2%)。结论术前下肢静脉造影及结合Pratt试验定位交通支,术中膝关节上上止血带,术后应用弹力绷带能较好预防SEPS术后筋膜下出血及皮下气肿的发生。     

腔镜与开放式甲状腺手术的临床对照研究

目的：比较腔镜与传统开放式甲状腺手术的临床效果。方法：对66例腔镜和57例开放式甲状腺手术的临床资料进行比较,指标为手术时间、出血量、术后住院时间及术后并发症等。结果：两组的年龄、性别、病种等无明显差异,平均手术时间腔镜组为（178.3±32.4）min、开放组为（145.8±27.1）min,平均出血量腔镜组为（19.1±12.4）ml、开放组为（44.6±18.6）ml,2组差异有统计学意义（P〈0.01）。结论：腔镜甲状腺手术安全、可靠,与传统开放式手术相比具有切口小、不影响美观等优点。     

Long-term survival after gastrectomy and other surgeries for multiple primary cancers

Long-term follow-up (from 10 to 32 years) of patients who have undergone surgeries for synchronous and metachronous polyneoplasia is analyzed. Gastrectomy with resection of the colon was performed in 2 patients, right-sided nephrectomy and abdomino-perineal extirpation of the rectum--in 1, pancreatoduodenal resection with right-sided hemicolectomy and abdomino-anal resection of the rectum--in 1 patient. One of the patients with synchronous-metachronous tumors of the stomach and colon over 15 years was operated 5 times with intervals from several years to several months. A total number of adenocarcinomas removed in this patient was 10. Experience of long-term follow-up of patients with gastrointestinal polyneoplasia confirms expediency of these surgeries when direct contraindications (advanced cancer, severe concomitant diseases) are absent.     

Clinical results after revision and primary total hip arthroplasty

Results after 184 primary and 227 revision total hip arthroplasties were compared with an emphasis on rates of failure leading to reoperation and intra- and postoperative complications and on the clinical outcome of the nonrevised arthroplasties in the two series. The failure rate was 7% (11 of 156) in the primary series, versus 27% (54 of 195) in the revision series. The rate of complications was substantially higher after revision, due to 16% (36 of 227) intraoperative fractures of the femoral shaft and 6% (14 of 227) postoperative dislocations. Clinical assessment of the nonrevised arthroplasties in the two series revealed no difference with regard to relief of pain. For patients with concomitant disabling conditions functional outcome was inferior after revision, but for patients without such conditions the functional results of the two series were equal. The favorable clinical results of the nonrevised arthroplasties in the revision series must be seen in relation to the very high rate of failure leading to reoperation.