Does the reimbursement of anesthesiologists for intraoperative transesophageal echocardiography promote increased utilization?

OBJECTIVE: To determine whether access to reimbursement increases anesthesiologists' use of intraoperative transesophageal echocardiography (TEE). DESIGN: Survey. SETTING: United States. PARTICIPANTS: Members of the Society of Cardiovascular Anesthesiologists, local Medicare carriers. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In year 2000, local Medicare carrier policies specifically allowed some form of reimbursement to the attending anesthesiologist for intraoperative TEE in 15 states, but barred all forms of reimbursement in 16 states and Puerto Rico. Data regarding utilization and billing were available for 702 members of the Society of Cardiovascular Anesthesiologists from these jurisdictions who used TEE in their anesthetic practice. Billing patterns were found to vary significantly according to the local Medicare policy in effect (p = 0.004). Use of intraoperative TEE was found to be unrelated, however, to the reimbursement available from Medicare (p = 0.2 to 0.7). CONCLUSION: The use of intraoperative TEE by anesthesiologists does not seem to be related to the availability of reimbursement from Medicare.     

Does intraoperative transesophageal echocardiography predict pulmonary valve dysfunction during the Ross procedure?

OBJECTIVE: To determine the value of intraoperative transesophageal echocardiography for the assessment of the pulmonary valve anatomy and the pulmonary autograft performance in patients undergoing the Ross procedure. DESIGN: Open, prospective, observational survey. SETTING: Favaloro Foundation, single institution. PARTICIPANTS: Consecutive patients undergoing elective Ross procedure (n = 87). INTERVENTIONS: Pulmonary valve function and anatomy were assessed by transesophageal echocardiography and the surgeon. Pulmonary autograft function was assessed after implantation. Regurgitation was considered mild (+/4), moderate (++/4), moderate-to-severe (+++/4), and severe (++++/4). Patients were restudied during midterm follow-up. MEASUREMENTS AND MAIN RESULTS: The Ross procedure was done in 74 patients (85%). Overall mortality was 3.4%. Mean follow-up was 24 +/- 13 months. The Ross procedure was not done in 13 patients (15%): 6 patients had a bicuspid pulmonary valve, 6 patients had >3 mm fenestrations, and 1 patient had regurgitation. The surgeon diagnosed anomalies in the pulmonary valve through direct observation. Transesophageal echocardiography was not sensitive enough to diagnose pulmonary valve defects in 12 of 13 patients with anomalies. Pulmonary valve regurgitation was identified by intraoperative transesophageal echocardiography in only 1 patient. Autograft regurgitation was 1.07 +/- 0.35 at postoperative evaluation. At 1, 6, and 12 months, it was 1.25 +/- 0.7 (p = 0.18), 1.27 +/- 0.9 (p = 0.185), and 1.29 +/- 0.8 (p = 0.17). The difference in values was not statistically significant. Four patients (5.4%) showed an increase in regurgitation during the first transthoracic autograft control. CONCLUSION: Intraoperative transesophageal echocardiography allows assessment of autograft performance after implantation. This method is not helpful, however, in detecting pulmonary valve anatomic anomalies.     

Are frozen sections useful and cost-effective in the era of intraoperative qPTH assays?

BACKGROUND: Since intraoperative quick parathormone (IOqPTH) assays are available, the role of frozen sections (FS) during parathyroid exploration has become questionable. This study compares the results of FS and IOqPTH in primary hyperparathyroidism (pHPT). METHODS: FS and IOqPTH assays were performed in 102 patients who underwent bilateral neck explorations or targeted parathyroidectomy for pHPT. The operation was considered complete when both an IOqPTH drop >50% and a FS diagnosis of parathyroid adenoma were obtained. RESULTS: Cure was achieved in all patients. Potential pitfalls for successful operation were encountered in 14 patients with multiglandular diseases and in 4 patients who had nonparathyroid tissue removed. FS correctly predicted the definitive histologic diagnosis with an accuracy of 81%. FS failures potentially misguided the operative therapy in 19% (14 insufficient explorations and 5 unnecessarily prolonged explorations), while IOqPTH identified all potential pitfalls and correctly guided the operative strategy, suggesting further exploration, in 100% of cases (P < .0001). After bilateral neck exploration, FS and IOqPTH correctly guided operative strategy in 86% and 100% of cases, respectively (P < .05), but both techniques were never indispensable, because potential pitfalls were already evident by macroscopic intraoperative appearance. The turnaround time and costs for IOqPTH were lower (P < .001). CONCLUSIONS: The role of FS should be reconsidered, since it can misguide the operative strategy. IOqPTH is indispensable for a focused approach and, although unnecessary in bilateral neck exploration, is more useful and cost-effective than FS.     

Does experience with laparoscopic colorectal surgery influence intraoperative outcomes?

Background  This study aimed to define the management and risk factors for intraoperative complications (IOC) and conversion in laparoscopic colorectal surgery, and to assess whether surgeon experience influences intraoperative outcomes. Methods  Consecutive patients undergoing laparoscopic colorectal procedures from 1991 to 2005 were analyzed from a longitudinal prospectively collected database. All patients referred to the four surgeons involved in this study were offered a minimally invasive approach. Patient characteristics, perioperative variables, and surgeon experience data were analyzed and compared. Results  A total of 991 consecutive laparoscopic colorectal procedures were studied. The majority of operations were performed for malignant disease (n = 526, 53%), and most frequently consisted of segmental colonic resections (n = 718, 72%). A total of 85 patients (8.6%) had an IOC. Patients experiencing an IOC had a significantly higher median body weight (75 versus 68 kg, p = 0.0047) and had a higher proportion of previous abdominal surgery (31% versus 20%, p = 0.029). Only 39% of patients suffering an IOC required conversion to open surgery. A total of 126 (13%) cases were converted to open surgery. On multivariable analysis, previous abdominal surgery [odds ratio (OR) 3.40, 95% confidence interval (CI) 1.39–8.35, p = 0.0076] was independently associated with having an IOC and a conversion to open within the same procedure. With increasing experience, individual surgeons were found to operate on heavier patients (p = 0.025), and on patients who had a higher rate of previous intra-abdominal surgery (p < 0.0001). Despite these risk factors, the early and late experience demonstrated no significant difference in terms of IOCs (p = 0.54) and conversion to open surgery (p = 0.40). Conclusions  The majority of IOCs can be managed laparoscopically. With increasing experience surgeons can perform laparoscopic colorectal surgery on a patient population with a greater proportion of previous abdominal surgery and a higher mean body weight without adversely affecting their rates of intraoperative complications or conversion. Oral presentation at the Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons, April 12th, 2008, Philadelphia, PA.     

The Pringle maneuver in laparoscopic hepatic surgery: is it useful? Analysis of a series of 38 cases

The Pringle maneuver is the most feasible method to control bleeding in hepatic resections in both open and laparoscopic approach. However its role in the mini-invasive surgery is still questionable. The aim of this study is to analyze our experience and to compare it to the literature data. This is a retrospective cohort study that includes all hepatic laparoscopic resections performed in our department between 1998-2007 and excludes all exploratory laparoscopies and all cases in which conversion to open procedure was imposed after the lesion assessment and in the absence on any intraoperative event. 38 hepatic laparoscopic resections were performed for both benign lesions (20 out of which 13 hemangiomas, 2 focal nodular hyperplasia, 1 liver cell adenoma, 2 hydatic cysts, 2 inflammatory lesions) and malignant lesions (18 out of which 8 metastases, 9 hepatocellular carcinoma, 1 cholangiocarcinoma). The tumor diameter ranged between 2 and 10 cm. There were 2 conversions to open procedures due to bleeding from hepatic veins collaterals. Pringle maneuver was never used. Pringle maneuver did not prove to be useful in our series because, on one hand, we performed only limited laparoscopic hepatic resections and, on the other hand, intraoperative bleeding was mainly due to lesions of the hepatic veins collaterals which cannot be influenced by clamping the hepatic pedicle. Even if there is no consensus, major laparoscopic hepatic resections may benefit from Pringle maneuver.     

Does the use of intraoperative CT scan improve outcomes in Orthopaedic surgery? A systematic review and meta-analysis of 871 cases

BackgroundIntraoperative imaging is frequently made use of in Orthopaedic surgery. Historically, conventional 2-dimensional fluoroscopy has been extensively used for this purpose. However, 2D imaging falls short when it is required to visualise complex anatomical regions such as pelvis, spine, foot and ankle etc. Intraoperative 3D imaging was introduced to counter these limitations, and is increasingly being employed in various sub-specialities of Orthopaedic Surgery.ObjectivesThis review aims to outline the clinical and radiological outcomes of surgeries done under the guidance of intraoperative 3D imaging and compare them to those done under conventional 2D fluoroscopy.MethodsThree electronic databases (PubMed, Embase and Scopus) were searched for relevant studies that directly compared intraoperative 3D imaging with conventional fluoroscopy. Case series on intraoperative 3D imaging were also included for qualitative synthesis. The outcomes evaluated included accuracy of implant placement, mean surgical duration and rate of revision surgery due to faulty implants.ResultsA total of 31 studies from sub-specialities of spine surgery, pelvi-acetabular surgery, foot and ankle surgery and trauma surgery, having data on a total of 658 patients were analysed. The study groups which had access to intraoperative 3D imaging was found to have significantly increased accuracy of implant positioning (Odds Ratio 0.35 [0.20, 0.62], p = 0.0002) without statistically significant difference in mean surgical time (p = 0.57). Analysis of the studies that included clinical follow up showed that the use of intraoperative 3D imaging led to a significant decrease in the need for revision surgeries due to faulty implant placement.ConclusionThere is sufficient evidence that the application of intraoperative 3D imaging leads to precise implant positioning and improves the radiological outcome. Further research in the form of prospective studies with long term follow up is required to determine whether this superior radiological outcome translates to better clinical results in the long run.     

Management of urethrocutaneous fistula after hypospadias surgery �C An experience of thirty-five cases

Introduction:

The commonest complication following hypospadias repair is occurrence of urethrocutaneous fistula. The smaller fistulas (<2 mm) are easier to close with a simple closure whereas larger ones (>2 mm) with good vascular surrounding skin require a local skin flap closure for avoiding overlapping suture lines. For the recurrent/larger fistulas with impaired local surrounding skin - incidence of recurrence is significantly reduced by providing a waterproofing interposition layer.

Aims:

To study the effect of size, location, number of fistulas and surrounding tissues in selecting the procedure and its outcome. To identify various factors involved in the recurrence and to formulate a management in the cases where recurrence has occurred.

Patients and Methods:

This study of 35 cases of urethrocutaneous fistula repair was done from July 2006 to May 2009 to achieve better results in fistula management following hypospadias surgery.

Statistical analysis used:

X² test and Fisher''s exact test.

Results:

The overall success rate for fistula repair at first attempt was 89% with success rates for simple closure, layered closure and closure with waterproofing layer being 77%,89% and 100%, respectively. The second attempt success rate at fistula repair for simple closure and closure with waterproofing layer were 33% and 100%, respectively. At third attempt the two recurrent fistulas were managed by simple closure with a waterproofing interposition layer with no recurrence. All the waterproofing procedures in this study had a success rate of 100%.

Conclusions:

The treatment plan for a fistula must be individualized based on variables which has an effect on the outcome of repair and to an extent dictates the type of repair to be performed. The significantly improved success rates with the addition of a waterproofing layer suggests the use of this interposition layer should be done at the earliest available opportunity to prevent a reccurence rather than to reserve it for future options.     

The learning curve in short-stem THA: influence of the surgeon’s experience on intraoperative adjustments due to intraoperative radiography

Introduction

Short-stem THA has become increasingly popular over the last decade. However, implantation technique differs from conventional THA and thus possibly involves a distinct learning curve. The purpose of this study was to evaluate the value of intraoperative radiography and the influence of the surgeon’s experience on intraoperative adjustments in short-stem THA.

Methods

A total of 287 consecutive short-stem THAs, operated by a total of 24 senior consultants, consultants and residents in training, were prospectively included. Intraoperative radiography was performed after trial reduction. Preoperative planning and intraoperative outcome with regard to positioning, sizing of components as well as resulting offset and leg length were compared. Frequency, reason and type of intraoperative adjustments were documented in relation to the surgeon’s experience. Operation time was assessed.

Results

One hundred and fifty-six (54.4%) procedures were carried out by one of three senior consultants, and a total of nine consultants and 12 residents in training performed 105 (36.6%) and 26 (9.0%) operations, respectively. In 121 cases (42.2%), intraoperative adjustments were made following intraoperative radiography. Intraoperative adjustments of one or more components were made by senior consultants in 51 cases (32.7%), by consultants in 53 cases (50.5%) and by residents in 17 cases (65.4%), respectively. The most common cause was undersizing of the stem. Operation time varied markedly between groups of surgeons.

Discussion

Short-stem THA involves a learning curve. Intraoperative radiography is decisive for prevention of malpositioning and undersizing of components, as well as loss of offset and leg length discrepancies. Hence, it should be considered mandatory, especially for less experienced surgeons.

     

Is laparoscopic intraoperative cholangiogram a matter of routine?

BACKGROUND: Intraoperative cholangiography during laparoscopic cholecystectomy reveals the anatomy of the biliary tree and any stones contained within it. The use of intraoperative cholangiography may be routine for all laparoscopic cholecystectomy. An alternative approach is a selective policy, performing intraoperative cholangiography only for those cases in which choledocholithiasis is suspected on clinical grounds, or those for which the anatomy appears unclear at operation. The literature pertaining to both approaches is reviewed, to delineate their respective merits. METHODS: Relevant articles in English were identified from the Medline database, and reviewed. RESULTS: The literature reviewed consisted of retrospective analyses. Overall the incidence of unsuspected retained stones was 4%, but only 15% of these would go on to cause clinical problems. The incidence of complete transection of the common bile duct was rare for both routine and selective intraoperative cholangiography policies, and did not differ between them. Rates of minor bile duct injury did not differ between groups, but was more likely to be recognized in the routine group than the selective (P = 0.01). CONCLUSIONS: Routine intraoperative cholangiography yields very little useful clinical information over and above that which is obtained with selective policies. Large numbers of unnecessary intraoperative cholangiography are performed under routine intraoperative cholangiography policy, and therefore a selective policy is advocated.     

Normothermic CPB in congenital heart disease—an experience of 653 cases

Background  

Lichenstein first established normothormic cardio pulmonary bypass as safe and effective method. We have been using normothromic CPB in all case including infants and neonates. The safety and efficacy in 653 congenital heart disease cases were retrospectively analyzed.     

Adrenocortical carcinoma – our experience with 11 cases

BACKGROUND AND AIMS: Adrenocortical carcinoma (ACC) is a rare tumour with an incidence of approximately 0.5-2 cases per million per year. Diagnosis is mostly delayed and prognosis is poor. We report our experiences with 11 patients operated on within the last 10 years. PATIENTS/METHODS: The data of the patients with ACC were reviewed and presenting symptoms, diagnostic procedures, treatment and results of follow-up were evaluated. RESULTS: The group of patients consisted of eight women and three men with a mean age of 40.2 (15-57) years. Median follow-up was 16 (1-71) months. Six patients presented with Cushing's syndrome, two presented with virilism and hirsutism caused by androgen-producing tumours. Three patients had hormonally inactive tumours. At the time of diagnosis, five tumours were classified as stage II, two as stage III and four as stage IV. Four patients had tumours with intravascular extension, prompting recurrence in two cases. Eight adrenalectomies, one resection of local recurrence, one adrenalectomy with splenectomy and one adrenalectomy and resection of a liver metastasis were performed. Five patients received additional chemotherapy. Five of the 11 patients are still alive (three stage II, one stage III and one stage IV at the time of diagnosis), three of whom have no evidence of disease (14, 48 and 71 months after surgery). The other six patients died after a median postoperative period of 10 (1-21) months. CONCLUSIONS: Venography should be performed prior to surgery to detect or exclude thrombotic tumour masses in the suprarenal vein, renal vein or inferior vena cava. Radical surgery is the only curative approach and is recommended for all patients with resectable tumours, including those patients with recurrent disease. There is no consensus concerning adjuvant therapy. The value of multidisciplinary strategies needs to be assessed in multicentre trials.     

Pediatric combined liver–kidney transplantation: a single-center experience of 18 cases

Background

Experience in combined liver–kidney transplantation (CLKT) in children is limited.

Methods

We conducted a retrospective study of all pediatric CLKTs performed at our medical institution between 1992 and 2013.

Results

We identified 18 pediatric patients (9 girls) who had undergone CLKT at our institution during the study period. The median age [range] and body weight [range] of this patient group was 3.6 [1.0–18.6] years and 13 [10–40] kg, respectively; 11 patients weighed <15 kg at the time of CLKT. Indications for CLKT were primary hyperoxaluria (PH1; n?=?14), association of hepatic fibrosis and end-stage renal disease (n?=?3) and methylmalonic acidemia (n?=?1). In the early postoperative period, eight patients required dialysis. Median stay in the pediatric intensive care unit was 10 [6–29] days. One patient died from cardiovascular disease 10 years after CLKT. There were no liver graft losses despite six acute liver rejection episodes, whereas four kidney grafts were lost. At last follow-up (6 [0.5–21] years) for patients with a functioning renal graft, the glomerular filtration rate was 71 [26–146] mL/min/1.73 m². In PH1 patients, urine oxalate normalized in six patients within 3 years after CLKT, but three patients still presented with elevated oxaluria at 1, 2 and 3 years after CLKT.

Conclusions

Pediatric CLKT provides encouraging results in the long term, even in the youngest patients.