Endocrine Surgery: Principles and Practice:adrenal chapter

The paired adrenal (suprarenal) glands are flattened retroperitoneal endocrine glands closely applied to the medial aspect of the superior pole of each kidney. The internal structure of these pale yellow glands are incongruous in that the adrenal gland is composed of two discrete parts, namely an outer cortex enveloping a central medulla. The adrenal cortex and medulla contain distinct endocrine tissues that secrete different hormones and are regulated by separate control systems.

Distribution and visual impact of postoperative refractive error after cataract surgery in rural China: study of cataract outcomes and up-take of services report 4.

PURPOSE: To model the possible impact of using average-power intraocular lenses (IOLs) and evaluate the postoperative refractive error in patients having cataract surgery in rural China.SETTING: Rural Guangdong, China.METHODS: Patients having cataract surgery by local surgeons were examined and visual function was assessed 10 to 14 months after surgery. Subjective refraction at near and distance was performed bilaterally by an ophthalmologist. Patients had a target refraction of -0.50 diopter (D) based on ocular biometry.RESULTS: Of the 313 eligible patients, 242 (77%) could be contacted and 176 (74% of contacted patients, 56% overall) were examined. Examined patients had a mean age of 69.4 +/- 10.5 years. Of the 211 operated eyes, 73.2% were within +/-1.0 D of the target refraction after surgery. The best presenting distance vision was in patients within +/-1.0 D of plano and the best presenting near vision, in those with mild myopia (<-1.0 D to > or =2.0 D) (P= .005). However, patients with hyperopia (>+1.0 D) reported significantly better adjusted visual function than those with emmetropia or myopia (<-1.0 D). When the predicted use of an average-power IOL (median +21.5 D) was modeled, predicted visual acuity was significantly reduced (P= .001); however, predicted visual function was not significantly altered (P>.3).CONCLUSIONS: Accurate selection of postoperative refractive error was achieved by local surgeons in this rural area. Based on visual function results, aiming for mild postoperative myopia may not be suitable in this setting. Implanting average-power IOLs significantly reduced postoperative presenting vision, but not visual function.

Clinical and cost-effectiveness of internal limiting membrane peeling for patients with idiopathic full thickness macular hole. Protocol for a Randomised Controlled Trial:FILMS (Full-thickness macular hole and Internal Limiting Membrane peeling Study)

Background: A full-thickness macular hole (FTMH) is a common retinal condition associated with impaired vision. Randomised controlled trials (RCTs) have demonstrated that surgery, by means of pars plana vitrectomy and post-operative intraocular tamponade with gas, is effective for stage 2, 3 and 4 FTMH. Internal limiting membrane (ILM) peeling has been introduced as an additional surgical manoeuvre to increase the success of the surgery; i.e. increase rates of hole closure and visual improvement. However, little robust evidence exists supporting the superiority of ILM peeling compared with no-peeling techniques. The purpose of FILMS (Full-thickness macular hole and Internal Limiting Membrane peeling Study) is to determine whether ILM peeling improves the visual function, the anatomical closure of FTMH, and the quality of life of patients affected by this disorder, and the cost-effectiveness of the surgery. Methods/Design: Patients with stage 2-3 idiopathic FTMH of less or equal than 18 months duration (based on symptoms reported by the participant) and with a visual acuity = 20/40 in the study eye will be enrolled in this FILMS from eight sites across the UK and Ireland. Participants will be randomised to receive combined cataract surgery (phacoemulsification and intraocular lens implantation) and pars plana vitrectomy with postoperative intraocular tamponade with gas, with or without ILM peeling. The primary outcome is distance visual acuity at 6 months. Secondary outcomes include distance visual acuity at 3 and 24 months, near visual acuity at 3, 6, and 24 months, contrast sensitivity at 6 months, reading speed at 6 months, anatomical closure of the macular hole at each time point (1, 3, 6, and 24 months), health related quality of life (HRQOL) at six months, costs to the health service and the participant, incremental costs per quality adjusted life year (QALY) and adverse events. Discussion: FILMS will provide high quality evidence onthe role of ILM peeling in FTMH surgery. © 2008 Lois et al; licensee BioMed Central Ltd.

Mitomycin-C supplemented trabeculectomy, phacoemulsification, and foldable lens implantation

Purpose: To evaluate the outcome of combined mitomycin-C filtering surgery, phacoemulsification, and foldable intraocular lens (IOL) implantation. Setting: Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA. Methods: This retrospective study evaluated 182 eyes of 174 patients who had combined mitomycin-C trabeculectomy, phacoemulsification, and insertion of a foldable IOL through a 3.5 mm incision. Success of the combined procedure was defined as intraocular pressure (IOP) below 21 mm Hg, with or without medications, and no serious complication. Success rates were calculated using the Kaplan-Meier actuarial method. Results: Mean follow-up was 16.7 months ± 5.4 (SD). The probability of success at 6, 12, 18, and 24 months was 98.3, 95.6, 90.6, and 88.0%, respectively. When compared with preoperativety, visual acuity improved one or more lines in 148 eyes (81.3%) and worsened one or more lines in 15 (8.2%); 111 eyes (61.0%) achieved visual acuity of 20/40 or better. The most frequent complication was posterior capsule opacification requiring capsulotomy, which occurred in 22 cases (12.0%). Conclusion: The 1 year and 2 year IOP control rate of combined mitomycin-C filtering procedures and phacoemulsification in glaucoma patients was high.

Artificial urinary sphincter implantation in the irradiated patient:safety, efficacy and satisfaction

Objective To compare the long-term outcome of artificial urinary sphincter (AUS) implantation in patients after prostatectomy, with and with no history of previous irradiation.

Patients and methods The study included 98 men (mean age 68 years) with urinary incontinence after prostatectomy for prostate cancer (85 radical, 13 transurethral resection) who had an AUS implanted. Twenty-two of the patients had received adjuvant external beam irradiation before AUS implantation. Over a mean (range) follow-up of 46 (5-118) months, the complication and surgical revision rates were recorded and compared between irradiated and unirradiated patients. The two groups were also compared for the resolution of incontinence and satisfaction, assessed using a questionnaire.

Results Overall, surgical revision was equally common in irradiated (36%) and unirradiated (24%) patients. After activating the AUS, urethral atrophy, infection and erosion requiring surgical revision were more common in irradiated patients (41% vs 11%; P <0.05); 70% of patients reported a significant improvement in continence, regardless of previous irradiation. Patient satisfaction remained high, with >80% of patients stating that they would undergo surgery again and/or recommend it to others, despite previous Irradiation and/or the need for surgical revision.

Conclusions Despite higher complication and surgical revision rates in patients who have an AUS implanted and have a history of previous Irradiation, the long-term continence and patient satisfaction appear not to be adversely affected.

Foreskin surgery under local anaesthetic – OK? Or oh no!

Aim: Foreskin surgical procedures such as circumcision, prepuceplasty, frenuloplasty, dorsal slit, reduction of paraphimosis etc. in the adult male is usually performed by both general surgeons and urologists. Our aim was to evaluate the acceptance of performing these procedures in the day procedure unit or in the emergency unit under penile block. 
Method: Fifty patients who underwent foreskin surgeries under local anaesthetic (LA) were evaluated with their experience. Twenty patients who underwent circumcision, 20 patients who underwent foreskin preserving operations such as frenuloplasty or prepuceplasty and 10 patients who underwent other procedures such as reduction of paraphimosis (five) and dorsal slit (five) were included inthe study. The patients were asked about their symptoms such as pain or discomfort during local infiltration of lignocaine, any discomfort during the actual procedure, post-operative discomfort and general acceptance. All the patients were given penile block using smaller size needle (25 gauge, 5/8th inch orange sterile luer slip hypodermic needle) and 1% plain lignocaine. Thirty doctors from general surgery (10), urology (10) and emergency medicine (10) participated in the survey. They were asked about their opinion, confidence and preference about performing foreskin surgical procedures under LA. This included both junior trainees, middle grade doctors and consultants. The majority of middle grade doctors and consultants were fairly confident in performing procedures under LA, whereas the junior trainees in surgery, urology and emergency were lacking confidence. 
Conclusion: Penile block is a safe and effective way ofproviding sufficient anaesthesia for foreskin surgeries. Thetechnique is easy to learn. It reduces post-operative pain aswell. It can reduce the risk and cost of administering generalanaesthesia. doctors who are in training surgical specialityand emergency medicine should be encouraged to learnthe principles and technique in administering penile block.

Cancellous bone repair using bovine trabecular bone matrix particulates.

At 5 and 15 weeks post-surgery, biomechanical and histological analyses of cancellous bone defects filled with the bovine trabecular bone matrix (BBM) and hydroxyapatite (Hap) particulates of dimensions 106–150 µm were investigated. It was observed that at 5 weeks post-surgery the stiffness properties of the BBM filled defects were significantly higher than those observed in the Hap filled defects (p

Posterior capsule opacification in mice

Objective: To present a new model of posterior capsule opacification (PCO) in mice. Methods: An extracapsular lens extraction was performed in 28 consecutive mice. Animals were humanely killed 0 and 24 hours and 3 and 14 days after surgery. Eyes were enucleated and processed for light microscopy and immunohistochemistry. Results: In 20 animals (71%), the eye appeared well healed before death. In 8 animals (29%), postoperative complications were noted. All animals developed PCO 2 weeks after surgery. Immediately after extracapsular lens extraction, lens epithelial cells were present in the inner surface of the anterior capsule and at the lens bow. At 24 hours, lens epithelial cells started to migrate toward the center of the posterior capsule. At 3 days, multilayered lens epithelial cells throughout the lens capsule and capsular wrinkling were apparent. Lens fibers and Soemmerring ring formation were observed 14 days after surgery. CD45 and CD11b macrophages were found in greater numbers 24 hours and 3 days after surgery (CD45 , P = .04 and P <.001, respectively; and CD11b , P = .01 and P = .004, respectively). The number of CD45 cells remained statistically significantly higher (P = .04) 14 days after surgery. Conclusion: In mice, PCO occurs following extracapsular lens extraction and is associated with low-grade but significant macrophage response. Clinical Relevance: The use of genetically modified mice to evaluate the pathogenic mechanisms of PCO and search for new therapeutic modalities to prevent or treat PCO is now possible.

Functional outcomes of decompressive hemicraniectomy following malignant middle cerebral artery infarctions: a systematic review

Decompressive hemicraniectomy has been used increasingly in recent years to treat malignant middle cerebral artery territory infarction. This review examines functional outcome data, with the novel analysis of outcomes according to temporal periods post-surgery. Case series data were pooled to determine significant correlates of outcome. Severe disability was frequently the outcome among survivors within one month post-surgery. Time and rehabilitation were later reflected, with fewer deaths and the emergence of mild to moderate disability increasing in prevalence. Mortality and severe disability were consistently more probable with increasing age. Presurgical clinical status in the form of additional cerebral artery involvement and midline shift also correlated with mortality within the 30-day period post-stroke.