Chest radiographs after dilatational percutaneous tracheotomy: are they necessary?

BACKGROUND: The efficacy of routinely obtaining chest radiographs after standard open tracheotomy has been questioned. Recent literature would suggest that after a routine, uncomplicated tracheotomy, chest radiography is a low-yield procedure that incurs unnecessary expense. Percutaneous dilatational tracheotomy (PDT) is rapidly replacing open tracheotomy as the intensive care unit procedure of choice for airway management. Complication rates are equivalent between the two procedures. OBJECTIVE: We examined the value and cost-effectiveness of routine postoperative chest radiographs in patients undergoing PDT. Study Design and Setting: The study was a prospective analysis of 54 consecutive PDTs performed at a tertiary care academic institution. RESULTS: Eighteen (33%) patients had chest radiographs obtained within 1 hour of PDT (6 at the request of the otolaryngology service); 35 (66%) underwent radiography more than 2 hours later at the request of the intensive care unit for reasons other than PDT. There were no incidents of pneumothorax, pneumomediastinum, or tracheotomy tube malposition in any patient. Patients undergoing chest radiography within 1 hour of the PDT also had chest radiographs within 12 hours at the request of ICU staff for their underlying disease. CONCLUSIONS: Routine chest radiography after PDT is of low yield. Because most of these patients require chest radiographs for their underlying disease within 12 hours, a cost savings of approximately $13,500 would be realized in this patient population. SIGNIFICANCE: Routine chest radiography after PDT is unwarranted in most cases.     

Interposition flaps in transabdominal vesicovaginal fistula repairs: are they really necessary?

Objectives. To evaluate the use of interposition flaps in repairing vesicovaginal fistulas (VVFs) of benign and malignant etiologies. Interposition flaps are not routinely used in the repair of VVFs when the surrounding tissues appear healthy and well-vascularized, such as in a benign etiology.Methods. We retrospectively reviewed the charts of 37 women (mean age 49.1 years) at our institution who underwent transabdominal repair of their VVF by urologic surgeons between August 1978 and June 1999. The preoperative and postoperative medical records were reviewed.Results. Of the 37 VVFs repaired transabdominally, 29 had a benign etiology (25 related to gynecologic procedures) and 8 a malignant etiology (all related to gynecologic neoplasia). Of the 29 benign VVFs, an interposition flap was used in 10 repairs with all 10 successful (100%). The remaining 19 benign VVF repairs were performed without using a flap, with 12 successful (63%). Of the 8 malignant fistulas, an interposition flap was used in 2 repairs with both successful (100%). The remaining 6 malignant VVF repairs were performed without a flap, with 4 successful (67%).Conclusions. The results of our study indicate a higher success rate for transabdominal VVF repairs performed with an interposition flap (100% success rate at our institution). This observation holds true regardless of the appearance of healthy surrounding tissue or, more importantly, a benign or malignant etiology. We recommend interposition flaps in transabdominal repairs of VVFs, even in the cases of benign fistulas with well-preserved surrounding tissue.     

Repeat epididymovasostomies: are they worthwhile?

OBJECTIVE: To establish whether it is worthwhile repeating epididymovasostomy in men with persistent obstructive azoospermia. PATIENTS AND METHODS: The study included 24 men with obstructive azoospermia, persisting after previous surgery for blockage in the body or tail of the epididymes, who underwent repeat epididymovasostomy proximal to the previous anastomoses. Semen was re-analysed after 6 and 12 months, and information about pregnancy self-reported or determined by postal survey. RESULTS: The postoperative sperm concentration was >107 /mL in 15 patients (62%) and 10 female partners became pregnant (41%). Antisperm antibodies were present in nine patients and three of their partners became pregnant after the man received steroid therapy. Unilateral revision did not produce a favourable outcome. CONCLUSION: Having defined a favourable group of men with obstructive azoospermia by scrotal exploration, i.e. those with caudal epididymal blocks and patent vasa deferentia, initial technical failure should not preclude surgical revision of the anastomoses in selected cases.     

Left-handed surgeons: are they left out?

BACKGROUND: Left-handedness has been considered a simple inconvenience by some or something as convoluted as "the sinister," the Latin word for the left, by others. One in ten medical personnel is left-handed. The perceptions of left-handed surgeons regarding their laterality related inconveniences are unknown. OBJECTIVES: To determine the perceptions of left-handed surgeons and the way it has affected their surgical training and career. DESIGN AND SETTING: Web-based survey of left-handed surgeons. PARTICIPANTS: Left-handed surgeons in 2 boroughs of New York City, Manhattan and Brooklyn. METHODS: Distribution and completion of the survey. MAIN OUTCOME MEASURE: Career-oriented concerns of left-handed surgeons. RESULTS: Three percent of left-handed surgeons received laterality related mentoring during medical school. Ten percent of the programs mentored left-handed surgical residents, and 13% of the programs provided left-handed instruments during surgical residency. Laparoscopy and laparoscopic instruments did not eliminate the problems associated with instrument handling to left-handed surgeons. Ten percent of the left-handed surgeons expressed concerns when asked whether they would be comfortable being treated by another left-handed surgeon when they are the patients themselves. CONCLUSIONS: This study reveals the perceptions of left-handed surgeons in adapting to a right-handed world. Early laterality related mentoring in medical school and during surgical residency with provision of left-handed instruments might reduce the inconveniences of left-handed surgeons learning.