Three dimensional anatomy and virtual surgery for transobturator approach

IntroductionStress Urinary Incontinence (SUI) may be managed by transobturator approach. We developed a threedimensional model, for understanding the surgical anatomy and manual training as well, in order to reduce the learning curve for pelvic surgeriesObjectiveTo demonstrate in synthetic models, the anatomical basis for the management of SUI and cystoceleMethodThe anatomical model includes: pelvic bones, the main layers of the pelvic muscles, ligaments and fascias. The surgical devices were transobturator needles, synthetic slings and meshes for anterior vaginal wall repair. The workshop was carried out with an anatomical overview and hands-on training in this tridimentional models and finally surgery in animals. At the end, a questionnaire was applied to verify the impact of this tool in the learning process and trainee satisfactionResultsAs far as the anatomical concept, 90% (n=72) of the participants classified this model as very good and 10% (n=8) as good. As a tool for understanding the tridimentional pelvic floor anatomy applied to transobturator procedures there were 100% of approvalConclusionsThis synthetic model allows for understanding the pelvic floor tridimentional anatomy and surgical procedures as well. Further skill is got in the animal model reducing the learning curve for transobturator procedures     

Three dimensional CT reconstruction for the evaluation and surgical planning of facial fractures

Despite advances in radiology--including CT scanning--the three-dimensional (3D) nature of facial fractures must still be inferred by the spatial imagination of the physician. A computer system (Insight Phoenix Data Systems, Inc., Albany, N.Y.) uses CT studies as substrate for 3D reconstructions. We have used the Insight computer for the evaluation and surgical planning of facial fractures of 16 patients with complex injuries. We present five illustrative cases, directly photographed from the computer monitor. Images can also be manipulated in real time by rotating or planar sectioning (functions best appreciated on video). The ability to cybernetically extract the facial skeleton from living subjects provides precise anatomic data previously unobtainable. The images are valuable for an accurate assessment of the relationship between the injured and uninjured sections of the face. We conclude that 3D reconstruction is an important advance in the treatment of facial fractures.     

Diagnostic validity of computed tomography for mediastinitis after cardiac surgery.

BACKGROUND: Optimal treatment based on appropriate early diagnosis is essential in managing mediastinitis after cardiac surgery. We evaluated the accuracy of thoracic computerised tomography (CT) in the diagnosis of mediastinitis. METHODS: Forty-one patients in whom we performed CT after cardiac surgery were classified into two groups as follows; Six cases had mediastinitis requiring a redo surgical intervention (Group M). Thirty-five cases recovered without mediastinitis (Group C). Comparisons of CT findings in both groups were made retrospectively. RESULTS: In group M, CT and re-operations were performed 6.3+/-2.5 days and 8.0+/-5.2 days after previous operation, respectively. All but one of redo surgical procedures were mediastinal lavage and omental transplantation. Two patients died due to septic shock and multiple organ failure. CT in group M showed a soft tissue mass with contrast enhancement in 4 patients, bilateral pleural effusion in 5, free gas appearance in 4, and sternal dehiscence or destruction in 2 patients. Consequently, we regarded 4 of the 6 patients in this group as showing postoperative mediastinitis radiographically. In group C, CT performed 16.6+/-7.1 days after operations revealed findings suggestive of mediastinitis in 6 patients. Therefore, in terms of the validity of CT for the diagnosis of mediastinitis, the sensitivity was 67% and the specificity was 83%. CONCLUSION: The sensitivity of CT for diagnosis of mediastinitis after cardiac operations is unsatisfactory. Diagnosis by seeking infective changes in a multidisciplinary way is important in dealing with mediastinitis.     

Myocardial infarct imaging after cardiac surgery.

One hundred and nineteen patients undergoing cardiac surgery had postoperative myocardial imaging performed with technetium pyrophosphate in order to assess the incidence of perioperative myocardial infarction. Fifty-six patients had only coronary artery bypass graft (CABG) surgery, of whom 13(23%) had a positive scintigram. Thirteen patients had CABG with other cardiac surgery and six (46%) had a positive scintigram. Fifty patients had other cardiac surgery but no CABG, and of these eight (16%) had a positive scintigram. The overall incidence of positive scintigrams was 23%, whereas definite or probable ECG diagnosis of infarction was present in 14 patients (12%). Serum levels of cardiac enzymes were higher in patients with positive scintigrams, but this finding did not consistently reach statistical significance. The use of a left ventricular vent during surgery did not correlate with a positive scintigram, nor did the total time on cardiopulmonary bypass or aortic cross-clamping. Patients having cardiac surgery, including CABG and valve replacement, have a 23% overall incidence of positive scintigrams. This suggests that the incidence of infarction after cardiac surgery is higher than can be recognized from the conventional criteria of ECG and enzyme changes.     

3-Dimensional computed tomographic angiography for use of surgery planning in patients with intracranial aneurysms

Summary Background. After subarachnoid haemorrhage (SAH) diagnostic evaluation of the underlying cause is warranted since the rebleeding rate is high. The objective of the study was to answer the question, whether 3-Dimensional computed tomographic angiography (3D-CTA) is able to accurately determine the surgical indications in patients with intracranial aneurysms. Methods. After performing 3D-CTA the size of the aneurysm, direction of the aneurysmal dome, neck position and variants of the circle of Willis were analysed. Surgery was performed solely on CTA data in those cases, where the aneurysm was clearly visible. If the findings were negative or inconclusive, intra-arterial digital subtraction angiography (DSA) was also done. Findings. Between January 2001 and December 2002 100 patients (68 F, 32 M) were examined and 123 aneurysms (86 ruptured and 37 unruptured) were diagnosed. All patients received CTA preoperatively and in 27 patients selective DSA was additionally performed. Postoperatively in 34 patients the operative result was checked by DSA. A good correlation between CTA and the intra-operative findings was present in 92 of 100 patients. One aneurysm was not seen on CTA, but was on DSA. In four cases we could confirm DSA findings in CTA after re-evaluation of the data. In three cases neither CTA nor DSA clearly showed an aneurysm, but it was confirmed during surgery. A good correlation between CTA and DSA was found in 60 of 61 patients (98%). The correlation between CTA and intra-operative findings was good as expected in 92 patients, in 5 patients an aneurysm was detected on re-evaluation. Only one aneurysm could not be demonstrated by CTA but in DSA. Conclusion. CTA is less invasive, less time consuming, cheaper and easier to demonstrate the essential information regarding the aneurysm than DSA. We therefore recommend that following a careful analysis most aneurysms – 92% – can be operated solely on CTA data. Contributed equally.     

Immediate functional benefits after controlled reperfusion during surgical revascularization for acute coronary occlusion.

This study tests the hypothesis that contractile dysfunction that often develops after acute coronary occlusion despite emergency revascularization can be avoided by careful control of the composition of the initial reperfusate and the conditions of the reperfusion. Between January 1987 and May 1989, 31 consecutive patients with acute coronary occlusion (90% resulting from percutaneous transluminal coronary angioplasty failures) were reperfused during emergency myocardial revascularization according to one of two different protocols. In 23 patients the reperfusate was normal blood given at systemic pressure ("uncontrolled reperfusion"); in eight patients the ischemic segment was reperfused during the first 20 minutes with a regional blood cardioplegic solution (substrate-enriched, hyperosmotic, hypocalcemic, alkalotic, diltiazem-containing) at 37 degrees C at a pressure of 50 mm Hg. Thereafter total bypass was prolonged for an additional 30 minutes before extracorporeal circulation was discontinued ("controlled reperfusion"). Assessment of regional contractility (echocardiography, radionuclide ventriculography), electrocardiographic evidence of myocardial infarction, release of creatine kinase and isoenzyme of creatine kinase, and hospital mortality was performed. Regional contractility was quantified with a scoring system from 0 (normokinesis) to 4 (dyskinesis). Data are expressed as mean +/- standard error of the mean. Both groups were well matched for age, sex, and the distribution of the occluded artery. In the controlled-reperfusion group there was a greater prevalence of previous infarctions (63% versus 43%), additional significant stenosis (1.3 +/- 0.2 versus 0.8 +/- 0.2), and cardiogenic shock (38% versus 17%) compared with the uncontrolled-reperfusion group. Furthermore, the interval between coronary occlusion and reperfusion was significantly longer in the controlled-reperfusion group (4.0 +/- 0.5 versus 2.3 +/- 0.3 hr; p less than 0.05). Regional contractility returned to normal in all patients treated by controlled reperfusion (wall motion score = 0.8 +/- 0.3, normokinesis = 0, slight hypokinesis = 1). In contrast, regional contractility remained severely depressed after uncontrolled reperfusion with normal blood (score 2.5 +/- 0.2; p less than 0.05), with only four of 23 patients with a score less than 2 (2 = severe hypokinesis). Postoperatively enzymes and electrocardiographic changes were similar in both groups. One patient died of mitral insufficiency in the controlled-reperfusion group, despite complete recovery of wall motion in the angioplasty-related artery. Conversely, the four of 23 deaths after uncontrolled reperfusion occurred in patients who sustained infarct in the area of the coronary occlusion (mortality 13% versus 17%). In conclusion, these preliminary clinical results indicate that immediate recovery of segmental contractility can be achieved after acute coronary occlusion if the initial reperfusion is controlled.(ABSTRACT TRUNCATED AT 400 WORDS)     

Use of computed tomographic reconstruction in planning osteotomies of the hip.

Certain deformities of the hip joint seem to predispose the hip to the development of osteoarthrosis. Successful surgical correction of these deformities before the onset of osteoarthrosis requires accurate characterization of the anatomic deviations from normal as the first step in planning corrective osteotomy. Three-dimensional computed tomography (CT) reconstruction in planning reconstructive hip osteotomy has most often been employed in developmental dysplasia of the hip. Computed tomography scanning with three-dimensional reconstruction can characterize the often complex deviations from normal in shape and attitude of acetabulum and femoral head in cases with residual hip dysplasia. Three-dimensional reconstruction also allows simulation of redirectional femoral or pelvic osteotomies to facilitate precise application of newer powerful surgical techniques for reorienting the acetabulum.     

Indication for coronary revascularization in aortic surgery

In order to know how to treat the coronary artery disease in scheduled aortic surgery for aortic aneurysms, a prospective study started about ten years ago using routine coronary angiography (CAG). Thoracic aortic aneurysm (TAA): CAG was performed in 73 among 143 patients and 18 had significant coronary artery stenoses (CAD), 3 of whom had angina. Concomitant CABG was performed in 2 of 4 patients requiring coronary revascularization (CR) to prevent intraoperative myocardial ischemia. Complications due to CAD were experienced in the 2 patients without CR despite of angina, while patients without angina or with CR had no complication. Abdominal aortic aneurysm (AAA): Seventy six among 150 patients had CAG, and CAD was found in 38. CR was indicated to 5 of 7 patients with angina. Complications occurred in 2 patients who had not CR in spite of angina. Patients without angina had no complication. Conclusion: 1) Patients who had angina are at high risk for complications due to CAD. 2) Patients with angina and necessity of cardiac arrest during aneurysmectomy should have coronary revascularization prior to aneurysmectomy. 3) Patients without angina are at low risk for myocardial ischemia in the perioperative period of aortic surgery.     

Transtricuspid approach in redo surgery for post-infarction ventricular septal rupture

A 59-year-old man, who had been treated using the infarction exclusion technique for inferior post-infarction ventricular septal rupture (VSR) 4 months previously, was readmitted because of deterioration of mitral valve regurgitation, residual shunt, and progression of pulmonary hypertension. We performed mitral valve replacement via the transseptal approach, patch closure of the defect via the transtricuspid approach, and tricuspid valve annuloplasty. The post-operative course was uneventful. The transtricuspid approach is useful in redo surgery for post-infarction VSR.     

Correlation between prior coronary revascularization and perioperative cardiac events in patients for noncardiac surgery

We evaluated the influence of interval between prior coronary revascularization and subsequent noncardiac surgery on perioperative cardiac events. We retrospectively identified 162 consecutive patients with previous revascularization procedures who had undergone noncardiac surgery. Postoperative cardiac complications occurred in 10 (6.2%) patients, cardiac death in 1 patient, and significant arrhythmia in 3 patients. These patients had higher rates of unstable angina, myocardial infarction within 3 months, cerebrovascular disease, peripheral vascular disease, renal dysfunction (Cr > or = 1.9 mg.dl-1) and higher preoperative risk scores as described by the Cleveland Clinic (P < 0.05). Also, the incidence of cardiac complications increased when noncardiac surgery was performed within 1 week of previous percutaneous transluminal coronary angioplasty (PTCA) and in more than 5 years after coronary artery bypass grafting or PTCA (P < 0.05). Although PTCA is widely accepted, especially in Japan, early lesion progression was observed during the first several days and atherosclerotic progression was apparent in more than 5 years after the procedure. Therefore, the time between coronary revascularization and noncardiac surgery, as well as atherosclerotic risk factors, is important in evaluating patients with history of previous revascularization procedures.     

CT perfusion imaging for childhood moyamoya disease before and after surgical revascularization

Summary Moyamoya disease is a progressive occlusive disease of the circle of Willis with prominent collateral arterial formation. We report on a 12-year-old girl with moyamoya disease presenting with transient ischemic attacks (TIAs). Surgical indirect revascularization was performed. The patient did not suffer further TIAs at 12 month follow-up. Pre and postoperative cerebral perfusion were studied in quantitative single photon emission computerized tomography (SPECT) and CT perfusion imaging. CT perfusion imaging demonstrated postoperatively increased cerebral blood flow as well as SPECT before and after revascularization. Furthermore, the area of decreased vascular reserve in SPECT with acetazolamide corresponded to areas of increased cerebral blood volume in CT perfusion imaging. CT perfusion imaging was equivalent to SPECT in accuracy, and superior in spatial resolution. CT perfusion imaging is likely to become more widely available as an easy-to-perform technique for assessing cerebral perfusion in a patients with moyamoya disease.