Symptomatic improvement after transmyocardial laser revascularization: how long does it last?

BACKGROUND: The aim of this study was to determine whether short-term clinical improvement after isolated transmyocardial holmium laser revascularization (TMLR) in patients with coronary artery disease not amenable to traditional treatment is maintained through a longer follow-up. METHODS: Between November 1995 and June 1999 34 patients underwent TMLR (mean age, 67+/-7 years); previous revascularization procedures had been performed in 76%. Preoperatively, mean angina class was 3.6+/-0.5 in 12 patients with unstable angina; mean left ventricular ejection fraction was 47%+/-9%. RESULTS: There was 1 early death due to low cardiac output. Mean duration of TMLR and of the entire operation was 25+/-12 minutes and 125+/-43 minutes, respectively. There were no major postoperative complications; mean hospital stay was 8+/-4 days. There were 8 late deaths caused by stroke (2 patients), cardiac failure (1 patient), and myocardial infarction (5 patients). Follow-up of current survivors ranges from 4 to 48 months (mean, 32+/-12 months). At 1-year follow-up mean angina class was 1.8+/-0.8; but at a later follow-up (mean, 35+/-10 months) it significantly increased to 2.2+/-0.7 (p = 0.005). Three-year actuarial survival was 76%+/-8% and freedom from cardiac events 44%+/-10%. CONCLUSIONS: Our results show that after initial clinical improvement many patients experience return of angina or cardiac events; this questions the long-term symptomatic benefit of TMLR.     

Off-pump coronary surgery: how do the anesthetic considerations differ?

In recent years, there has been much interest in performing coronary artery bypass graft (CABG) surgery without the aid of cardiopulmonary bypass (CPB). Initial efforts focused on "minimally invasive" direct coronary artery bypass, wherein the left anterior descending artery is bypassed with an in situ left internal mammary artery graft through a small left anterior thoracotomy. A more widely adopted approach however, is off-pump CABG (OPCAB), in which CABG surgery is performed on one or more vessels through the usual median sternotomy approach without the aid of CPB. This article reviews the differences in the anesthetic considerations of OPCAB compared to conventional CABG using CPB.     

Laparoscopic antireflux surgery: how I do it?

Gastroesophageal reflux disease (GERD) affects an estimated 20% of the population in the US, and its prevalence is increasing worldwide. Lifestyle modifications and proton pump inhibitors (PPI) are effective in the majority of patients. However, some patients will become candidates for surgical intervention, because they have partial control of symptoms, do not want to be on long-term medical treatment, or suffer complications related to PPI. In these patients, a properly executed laparoscopic antireflux surgery controls esophageal and extra-esophageal symptoms and avoids life-long medical therapy. Important technical elements should be taken into account during the operation to avoid troublesome side effects and obtain optimal postoperative outcomes.     

Surveillance neuroimaging of intracranial medulloblastoma in children: how effective,how often,and for how long?

OBJECT: The goal of this paper was to review brain and spine images obtained in children with medulloblastomas to determine the risk factors for tumor recurrence and to assess the impact of surveillance imaging on patient outcomes among patients who remain alive 1 month postsurgery. METHODS: Imaging studies and clinical data obtained in children with medulloblastomas, who presented between January 1987 and August 1998, were retrospectively reviewed. Images were termed surveillance if they were follow-up studies and symptom prompted if they were obtained to investigate new symptoms. One hundred seven patients (mean age 6 years and 3 months, range 2 months-15 years and 6 months) were entered into the study. Fifty-three children experienced tumor recurrence; 41 had one recurrence, nine had two, and three had three recurrences. Surveillance imaging revealed 10 of the first 53 recurrences and 15 of all 68 recurrences. When the first recurrence was identified by the emergence of symptoms (42 patients), the children tended to survive for a shorter time (hazard ratio 3.72, 95% confidence interval 1.42-9.76, p = 0.008) than children in whom the first recurrence was detected before symptoms occurred (10 patients). The median survival time following symptomatic tumor recurrence was 4 months and that after surveillance-detected tumor recurrence was 17 months. The median increased survival time among patients whose recurrence was asymptomatic and identified by imaging studies was 13 months, more than half the mean time between surveillance imaging sessions. Incomplete tumor resection was associated with a significantly reduced time to recurrence (p = 0.048) and to death (p = 0.002). The number of recurrences that were experienced was associated with a reduced time to death (p < 0.001). CONCLUSIONS: Surveillance imaging is associated with an increase in survival in children with medulloblastomas. More frequent surveillance imaging in children with incomplete tumor excision and recurrent disease may further improve the length of survival.     

Publishing in surgery: how and why?

Introduction

Evidence-based medicine continues to have an increasingly important impact on all surgical departments, with the art of publication becoming a skill in its own right and occupying an ever more central role. However, it remains a challenge for any surgeon to publish their work.

Purpose

The aims of this educational review are to understand why, what and where surgeons should publish and to provide surgeons with a guide regarding the publication process and the rules to be adhered to.

Methodology

This review targets (1) any surgeon beginning their scientific publication activity, (2) more experienced surgeons who wish to optimise their ability to have their work published and finally (3) leaders of research departments who aspire to improve the quality of their publications and their research productivity and profile.     

Women in surgery: do we really understand the deterrents?

HYPOTHESIS: Women are deterred from a surgical career owing to a lack of role models rather than lifestyle considerations. DESIGN: Survey. SETTING: University teaching hospital. PARTICIPANTS: Surgery and obstetrics/gynecology attending physicians, residents, and medical students. INTERVENTION: Questionnaire. MAIN OUTCOME MEASURES: Potential deterrents to a surgical career. RESULTS: Men and women had a similar interest in a surgical career before their surgical rotation (64% vs 53%, P = .68). A similar percentage developed a mentor (40.0% vs 45.9%, P = .40). Women were far more likely to perceive sex discrimination (46.7% vs 20.4%, P = .002), most often from male attending physicians (33.3%) or residents (31.1%). Women were less likely to be deterred by diminishing rewards (4.4% vs 21.6%, P = .003) or workload considerations (28.9% vs 49.0%, P = .02). They were also less likely to cite family concerns as a deterrent (47.8% vs 66.7%, P = .02) and equally likely to be deterred by lifestyle during residency (83.3% vs 76.5%, P = .22). However, women were more likely to be deterred by perceptions of the "surgical personality" (40.0% vs 21.6%, P = .03) and the perception of surgery as an "old boys' club" (22.2% vs 3.9%, P = .002). CONCLUSIONS: Men and women are very similar in what they consider important in deciding on a surgical career. Women are not more likely to be deterred by lifestyle, workload issues, or lack of role models. However, the perceived surgical personality and surgical culture is a sex-specific deterrence to a career in surgery for women.     

The natural course of prevertebral soft tissue swelling after anterior cervical spine surgery: how long will it last?

Background Context

Prevertebral soft tissue swelling (PSTS) after anterior cervical spine surgery (ACSS) has been regarded as one of the critical complications that cause airway obstruction. Still, however, no research has dealt with how PSTS returns to presurgery status after ACSS; most recommendations are being performed without information about its natural course, focusing on acute-phase swelling after surgery.

Ethical regulations for innovative surgery: the last frontier?

Background:

There are no clear federal regulations governing innovative surgery, even though general guidelines regulating research with human subjects do exist. We hypothesized that US surgeons are unaware of Department of Health and Human Services regulations, rarely seek IRB review, generally oppose outside regulation of innovative surgery, and are uncertain what constitutes innovation and research. These circumstances, if true, would pose a significant ethical problem and present potential harm to patients as unwitting subjects of research.

Study Design:

In a pilot study we reviewed 527 issues of US surgical and medical journals, selecting 59 articles published between 1992 and 2000, that described innovative surgery. Corresponding authors from university hospitals (71%) and other facilities (29%) were sent an anonymous questionnaire.

Results:

The survey was conducted between November 2000 and May 2001. Twenty-one questionnaires were returned, completed with responses, constituting a 35% overall response rate. Fourteen authors confirmed their work was research, yet only six had sought prior IRB review. The majority of authors (15 of 21) did not submit their protocol to IRB. Only seven authors had mentioned the innovative nature of the procedure in the informed consent form. Seven authors claimed familiarity with Office for Human Research Protections definitions of research and human subject. Two-thirds of the respondents stated that government regulations for the protection of human subjects of innovative surgery would not be appropriate.

Conclusions:

The current system of definitions, ethical theories, and voluntary professional guidelines may be inadequate to meet the challenge of surgical innovation. Further research is proposed to examine the adequacy of the existing guidelines.