[Computer-aided surgery of the paranasal sinuses and the anterior skull base]

Endoscopic or microscopic surgery for chronic rhinosinusitis with or without nasal polyps is a routine intervention in daily practice. It is often a delicate and difficult minimally invasive intervention in a narrow space, with a tunnel view of 4 mm in the case of endoscopy and frequent bleeding in chronically inflamed tissue. Therefore, orientation in such a "labyrinth" is often difficult. In the case of polyp recurrence or tumors, the normal anatomical landmarks are often missing, which renders orientation even more difficult. In such cases, computer-aided navigation together with images such as those from computed tomography or magnetic resonance imaging can support the surgeon to make the operation more accurate and, in some cases, faster. Computer-aided surgery also has great potential for education.

International Common Otology Database: taste disturbance after stapes surgery

OBJECTIVE: To use a study on dysgeusia to assess the usefulness of an otology database. STUDY DESIGN: Data were extracted from the international Common Otology Database. INTERVENTION: Primary stapes operations. MAIN OUTCOME MEASURE AND RESULTS: From a cohort of 14 otologists, only 8 (57%) were able to satisfy external validation and maintain data input for a period of at least 6 months. The rates of dysgeusia varied from 0 to 39% at 3 months and 0 to 27% at 6 months. The percentages of patients with taste disturbance at 6 months in the "nerve-cut" and "nerve-preserved" groups were 22.7 and 10.9%, respectively, although this was not statistically significant (chi2; p = 0.325). CONCLUSION: Many surgeons found it difficult to maintain a prospective otology database. The rates of certain subjective symptoms such as dysgeusia are influenced by how vigorously the reviewers prompt the response from the patients. Dysgeusia after stapes surgery is common even if the chorda tympani nerve is preserved. Many patients whose chorda tympani nerve is divided may not complain of dysgeusia.

Advanced Lemierre syndrome requiring surgery

A 38-year-old homeless man was admitted with a 2-week history of a sore throat, increasing shortness of breath, and high fever. Clinical examination showed enlarged and tender submandibular and anterior cervical lymph nodes and a pronounced enlargement of the left peritonsillar region (Figure 1a). CT scan of the throat and the chest showed left peritonsillar abscess formation, occlusion of the left internal jugular vein with inflammatory wall thickening and perijugular soft tissue infiltration, pulmonary abscesses, and bilateral pleural effusions (Figures 1b-e, arrowed). Anaerobe blood cultures grew Fusobacterium necrophorum, leading to the diagnosis of Lemierre's syndrome. Treatment with high-dose amoxicillin and clavulanic acid improved the oropharyngeal condition, but the patient's general status declined further, marked by dyspnea and tachypnea. Repeated CT scans showed progressive lung abscesses and bilateral pleural empyema. Bilateral tonsillectomy, ligation of the left internal jugular vein, and staged decortication of bilateral empyema were performed. Total antibiotic therapy duration was 9 weeks, including a change to peroral clindamycin. Clinical and laboratory findings had returned to normal 12 weeks after surgery.The patient's history and the clinical and radiological findings are characteristic for Lemierre's syndrome. CT scans of the neck and the chest are the diagnostic methods of choice. F. necrophorum is found in over 80% of cases of Lemierre's syndrome and confirms the diagnosis. Prolonged antibiotic therapy is usually sufficient, but in selected patients, a surgical intervention may be necessary. Reported mortality rates are high, but in surviving patients, the recovery of pulmonary function is usually good.

Quality of life 15 years after sex reassignment surgery for transsexualism

OBJECTIVE: To evaluate quality of life and patients' satisfaction in transsexual patients (TS) after sex reassignment operation compared with healthy controls. DESIGN: A case-control study. SETTING: A tertiary referral center. PATIENT(S): Patients after sex reassignment operation were compared with a similar group of healthy controls in respect to quality of life and general satisfaction. INTERVENTION(S): For quality of life we used the King's Health Questionnaire, which was distributed to the patients and to the control group. Visual analogue scale was used for the determination of satisfaction. MAIN OUTCOME MEASURE(S): Main outcome measures were quality of life and satisfaction. RESULT(S): Fifty-five transsexuals participated in this study. Fifty-two were male-to-female and 3 female-to-male. Quality of life as determined by the King's Health Questionnaire was significantly lower in general health, personal, physical and role limitations. Patients' satisfaction was significantly lower compared with controls. Emotions, sleep, and incontinence impact as well as symptom severity is similar to controls. Overall satisfaction was statistically significant lower in TS compared with controls. CONCLUSION(S): Fifteen years after sex reassignment operation quality of life is lower in the domains general health, role limitation, physical limitation, and personal limitation.

Body contouring surgery following bariatric surgery and dietetically induced massive weight reduction: a risk analysis

BACKGROUND: This study analyzed the impact of weight reduction method, preoperative, and intraoperative variables on the outcome of reconstructive body contouring surgery following massive weight reduction. METHODS: All patients presenting with a maximal BMI >/=35 kg/m(2) before weight reduction who underwent body contouring surgery of the trunk following massive weight loss (excess body mass index loss (EBMIL) >/= 30%) between January 2002 and June 2007 were retrospectively analyzed. Incomplete records or follow-up led to exclusion. Statistical analysis focused on weight reduction method and pre-, intra-, and postoperative risk factors. The outcome was compared to current literature results. RESULTS: A total of 104 patients were included (87 female and 17 male; mean age 47.9 years). Massive weight reduction was achieved through bariatric surgery in 62 patients (59.6%) and dietetically in 42 patients (40.4%). Dietetically achieved excess body mass index loss (EBMIL) was 94.20% and in this cohort higher than surgically induced reduction EBMIL 80.80% (p < 0.01). Bariatric surgery did not present increased risks for complications for the secondary body contouring procedures. The observed complications (26.9%) were analyzed for risk factors. Total tissue resection weight was a significant risk factor (p < 0.05). Preoperative BMI had an impact on infections (p < 0.05). No impact on the postoperative outcome was detected in EBMIL, maximal BMI, smoking, hemoglobin, blood loss, body contouring technique or operation time. Corrective procedures were performed in 11 patients (10.6%). The results were compared to recent data. CONCLUSION: Bariatric surgery does not increase risks for complications in subsequent body contouring procedures when compared to massive dietetic weight reduction.

[Revision surgery after carpal tunnel release using a posterior interosseous artery island flap]

The aim of this study is to evaluate the results of fasciocutaneous posterior interosseous artery island flaps in the treatment of recurrent or persistent carpal tunnel compression syndrome (CTS).

Interrelation of peri-operative morbidity and ASA class assignment in patients undergoing gynaecological surgery

OBJECTIVE: The aim of this study was to estimate intra- and post-operative risk using the American Society of Anaesthesiologists (ASA) classification which is an important predictor of an intervention and of the entire operating programme. STUDY DESIGN: In this retrospective study, 4435 consecutive patients undergoing elective and emergency surgery at the Gynaecological Clinic of the University Hospital of Zurich were included. The ASA classification for pre-operative risk assessment was determined by an anaesthesiologist after a thorough physical examination. We observed several pre-, intra- and post-operative parameters, such as age, body-mass-index, duration of anaesthesia, duration of surgery, blood loss, duration of post-operative stay, complicated post-operative course, morbidity and mortality. The investigation of different risk factors was achieved by a multiple linear regression model for log-transformed duration of hospitalisation. RESULTS: Age and obesity were responsible for a higher ASA classification. ASA grade correlates with the duration of anaesthesia and the duration of the surgery itself. There was a significant difference in blood loss between ASA grades I (113+/-195 ml) and III (222+/-470 ml) and between classes II (176+/-432 ml) and III. The duration of post-operative hospitalisation could also be correlated with ASA class. ASA class I=1.7+/-3.0 days, ASA class II=3.6+/-4.3 days, ASA class III=6.8+/-8.2 days, and ASA class IV=6.2+/-3.9 days. The mean post-operative in-hospital stay was 2.5+/-4.0 days without complications, and 8.7+/-6.7 days with post-operative complications. Multiple linear regression model showed that not only the ASA classification contained an important information for the duration of hospitalisation. Parameters such as age, class of diagnosis, post-operative complications, etc. also have an influence on the duration of hospitalisation. CONCLUSION: This study shows that the ASA classification can be used as a good and early available predictor for the planning of an intervention in gynaecological surgery. The ASA classification helps the surgeon to assess the peri-operative risk profile of which important information can be derived for the planning of the operation programme.

Pediatric cranio-facial surgery. First-year's experience with a gun applying bioabsorbable tacks

AIM: In 2001 a prototype of a gun to apply bioabsorbable tacks in cranio-facial surgery has been developed. METHODS: From May 2001 to May 2002 this device has been used in the University Hospital of Innsbruck (Austria) for different cranioplasty procedures, in 34 children, showing its reliability for cranio-facial bone fixation. The children were affected by isolated craniosynostosis or by syndromical synostosis (Apert, Crouzon) and in a case of benign tumor of the parietal skull vault. The range of age, at the time of surgery, was between 3 months and 204 months of age. Bone segments were fixed using self-reinforced polylactide plates and tacks. RESULTS: Firm fixation was obtained intra-operatively and the operative time was reduced about 25-30 minutes as compared to use of plates and screws. This device has just one limitation in its own spring force: sometimes the bone thinner than 1 mm has been broken applying the tacks. CONCLUSION: After the first-year's experience it is possible to confirm that this device reduces, in selected cases, operative time, blood loss, risk of infection and, as a result, the costs.

Predictors of swallowing outcome in patients treated with surgery and radiotherapy for advanced oral and oropharyngeal cancer

Retaining effective swallowing is a key element when optimising outcomes in the management of head and neck cancer. We report the functional swallowing outcomes for a cohort of 31 individuals with advanced oral and oropharyngeal cancer who underwent free or pedicled flap reconstruction of surgical defects. Swallowing was assessed pre and immediately post surgery and at four months post treatment. Swallowing assessments were related to site, size and volume of defect and composition of flap reconstruction. The effect of radiotherapy on swallowing was assessed among 17 of the 31 individuals who were submitted to radiotherapy after surgery. The proportion of patients on a total oral diet four months post treatment varied significantly by site of defect (Fishers exact test p=0.006), from 100% (7/7) of patients with a lateral defect to only 22% (2/9) of patients with a central defect. The proportion of patients on a total oral diet at the final assessment did not vary by flap reconstruction or radiotherapy.

Minimally invasive strabismus surgery (MISS) for inferior obliquus recession

PURPOSE: To present a novel, minimally invasive strabismus surgery (MISS) technique for inferior obliquus recessions. METHODS: Graded MISS inferior obliquus recessions were performed in 20 eyes of 15 patients by applying two small conjunctival cuts, one at the insertion of inferior obliquus and another where the scleral anchoring of the muscle occurred. RESULTS: The amount of recession was 12.2 +/- 2.3 mm (range 6 to 14 mm). The vertical deviation, which was measured in 25 degrees of adduction, decreased from preoperatively 12.8 degrees +/- 5.6 degrees to 2.7 degrees +/- 2.2 degrees (p < 0.0001) at 6 months. LogMAR visual acuity was preoperatively -0.10 +/- 0.17 and at 6 months -0.14 +/- 0.22 (p > 0.1). In one eye (2.5%) the two cuts had to be joined because of excessive bleeding. Binocular vision improved in eight patients, remained unchanged in six patients, and decreased from 30 to 60 arcsec in one patient (p > 0.1). Conjunctival and lid swelling were hardly visible on the first postoperative day in primary gaze position in 10/20 (50%) of eyes. Five of the eyes (25%) had mild and five (25%) moderate visibility of surgery. One patient out of 15 (7%) needed repeat surgery because of insufficient reduction of the sursoadduction within the first 6 months. The dose-effect relationship 6 months postoperatively for an accommodative near target at 25 degrees adduction was 0.83 degrees +/- 0.43 degrees per mm of recession. CONCLUSIONS: This study demonstrates that small-incision, minimal dissection inferior obliquus graded recessions are feasible and effective to improve ocular alignment in patients with strabismus sursoadductorius.

Accuracy of navigated surgery of the pelvis after surface matching with an a-mode ultrasound probe

Computer-aided surgery (CAS) allows for real-time intraoperative feedback resulting in increased accuracy, while reducing intraoperative radiation. CAS is especially useful for the treatment of certain pelvic ring fractures, which necessitate the precise placement of screws. Flouroscopy-based CAS modules have been developed for many orthopedic applications. The integration of the isocentric flouroscope even enables navigation using intraoperatively acquired three-dimensional (3D) data, though the scan volume and imaging quality are limited. Complicated and comprehensive pathologies in regions like the pelvis can necessitate a CT-based navigation system because of its larger field of view. To be accurate, the patient's anatomy must be registered and matched with the virtual object (CT data). The actual precision within the region of interest depends on the area of the bone where surface matching is performed. Conventional surface matching with a solid pointer requires extensive soft tissue dissection. This contradicts the primary purpose of CAS as a minimally invasive alternative to conventional surgical techniques. We therefore integrated an a-mode ultrasound pointer into the process of surface matching for pelvic surgery and compared it to the conventional method. Accuracy measurements were made in two pelvic models: a foam model submerged in water and one with attached porcine muscle tissue. Three different tissue depths were selected based on CT scans of 30 human pelves. The ultrasound pointer allowed for registration of virtually any point on the pelvis. This method of surface matching could be successfully integrated into CAS of the pelvis.