Can hemifacial spasm lead to glaucomatous changes?

PURPOSE: To evaluate the association between hemifacial spasm (HFS) patients and glaucoma as a function of the Botox dosage required. METHODS: A retrospective review of clinical documents and procedure records. RESULTS: Information of 76 consecutive patients (58 females) with HFS who received Botox treatment were reviewed. The age at onset of HFS was 66±11 (32-85) years, and all manifested unilaterally. Ten (13%, 95% confidence interval: 6.5-22.9%) patients were diagnosed with glaucoma, including 8 primary open-angle glaucoma (POAG) (4 unilateral and ipsilateral to the HFS), and 2 bilateral chronic angle-closure glaucoma (CACG). Nine of the 10 patients developed glaucoma after the onset of the HFS. The Botox dosage was significantly higher among those diagnosed with glaucoma (31+/8 vs. 26+/7units, P<0.05). There was a positive relationship between the presenting intraocular pressure (IOP) and the Botox dosage required (R=0.31, P=0.0116). However, there was a weak relationship between the Botox dosage required and the vertical cup to disc ratio (R=0.076, P=0.525). The presenting IOP of the HFS-affected eyes in those diagnosed with glaucoma was higher than those without glaucoma (19±3.5 vs. 13±3.2mmHg, P=<0.05). The presenting IOP between the HFS-affected and unaffected eyes was similar (16±4.8 vs. 15+/4.6mmHg, P=0.430). Smoking status, history of diabetes mellitus, hypertension, hyperlipidemia and obstructive sleep apnea were not different between HFS patients with or without glaucoma. CONCLUSIONS: Hemifacial spasm patients with glaucoma were associated with a higher Botox dosage. We found a positive relationship between the Botox dosage required and the presenting IOP. Whether hemifacial spasm can result in fluctuation of IOP, eventually causing glaucomatous damage, remains to be studied further.

Minimal incision posterior approach levator plication for aponeurotic ptosis.

PURPOSE: To assess the efficacy and predictability of a minimal incision posterior approach levator plication technique for correction of involutional ptosis. METHOD: Retrospective chart review of patients with involutional aponeurotic ptosis underwent minimal incision posterior approach levator plication technique between August 2013 and June 2014 by a single surgeon. The upper lid was double everted, and the conjunctiva and Muller's muscle layers were incised vertically until the levator aponeurosis could be identified. The incision(s) was similar to performing incision and curettage of chalazion, except that the site was above the tarsal plate and extended towards the fornix. Then insertion of aponeurosis was dissected away from the anterior tarsal surface, and the more superiorly located levator was plicated on it with double arm suture(s). No tissue was excised in this procedure. Surgical success was defined as a postoperative margin reflex distance (MRD)>2 mm and<4.5 mm, interlid height<1 mm and satisfactory contour. RESULTS: Forty-four lids of 27 patients were included. Preoperative mean MRD was 0.48 +/- 0.56 mm. Severe ptosis of MRD<1 mm was present in 34/44 patients (77.3%). The postoperative mean MRD was 2.49 +/- 0.53 mm, and mean improvement was 2.02 +/- 0.61 mm, which was statistically significant (P<0.001). The overall success rate was 38/44 (86.4%). CONCLUSIONS: Minimal incision posterior approach to levator plication was effective for the correction of aponeurotic ptosis with moderate to good levator function.

Transanal Endoscopic Microsurgery (TEM): the first endoluminal endoscopic surgery.

The typical concept of endoscopic surgery is the performance of surgical procedures in the two major body cavities, the abdomen and thorax. To perform this, small incisions for the ports are needed to introduce optics and instruments. Typically, the optic and the instruments are introduced from different angles. The access itself is associated with a reduced trauma.

Transanal endoscopic microsurgery. Initial registry results.

UNLABELLED: Transanal endoscopic microsurgery (TEM) was first used on a regular basis in the United States in 1990. Because there is a sole source of instrumentation, the surgeons who use this equipment are known to us. Thus, this earliest registry is a compilation of data based on most patients who underwent TEM in the United States from 1990 to 1994. METHOD: One hundred fifty-three cases were voluntarily registered by six surgeons. Pathology included 54 carcinomas, 82 adenomas, and 17 other entities. Most resections were full thickness. Fifty percent of cases were out of reach of standard instruments. Complication rate, hospital stay, and blood loss were recorded. Technical difficulties at time of surgery (9 percent), early complications (15 percent), and late complications (5 percent) have been tabulated. RESULTS: Recurrence rates for carcinoma were 10 percent for T1, 40 percent for T2, and 66 percent for T3 stages. Failures were treated by abdominoperineal resection or low anterior resection. Adenomas recurred in 11 percent, but these recurrences were small and easily treatable. CONCLUSION: TEM has a low complication rate. By carefully selecting small, superficial cancers and adenomas, TEM results in superior outcome over other approaches to the mid and upper rectum.

Percutaneous endoscopic external ring (PEER) hernioplasty.

This pilot study was conducted to determine if percutaneous endoscopic external ring (PEER) hernioplasty would be a viable alternative to the conventional and laparoscopic methods of tension-free repair. The procedure consists of (1) a 2.0-2.5-cm incision over the external inguinal ring to reach the emerging spermatic cord structures, and ligation and excision of the hernia sac and (2) insertion of an endoscope-attached retractor through the external ring, into the inguinal canal for visualization, dissection of posterior inguinal wall, and placement of mesh to complete tension-free repair. PEER hernioplasty was used to treat 48 patients with 60 primary hernias (bilateral in 12 patients) between January 1993 and December 1994. Median follow-up was 12 months and ranged from 5 to 22 months. All patients were discharged within 24 h after surgery except for one. All patients resumed their normal activity within 2-3 weeks. Only three complications were encountered (two scrotal hematomas and one inguinal seroma). To date, there has been recurrence of two hernias in one patient. We conclude that PEER hernioplasty is an effective method of repair of primary hernias that is less invasive than the conventional approach and both less invasive and more cost-effective than laparoscopic approaches.

Credentialing, privileging, and proctoring in the era of laparoscopic surgery history of credentialing problems originating with laparoscopic surgery.

Laparoscopic surgery in the United States was revolutionized in 1989. Even though Semm had popularized laparoscopic surgery in the early 1980s in Germany, it was the advent of laparoscopic cholecystectomy in 1989 that triggered the explosive training and credentialing issues in laparoscopic surgery. In a letter to the editor of the American Journal of Surgery, in June 1990, the author had recommended the following for training courses: (1) the operators should have extensive hands-on experience in diagnostic laparoscopy prior to embarking on laparoscopic surgery; (2) hands-on training to develop hand-eye coordination using Berci-Sackier trainers; (3) extensive explanation on the use and abuse of videolaparoscope and accessory instrumentation; (4) a minimum experience as prime operator in at least 3 pigs, each weighing 90 to 100 lbs., with experience as an assistant operator and camera operator in 6 more pigs, making a total of 9 pigs per participant. This letter was written with the intent that proper training of surgeons would take place. We advocated a surgeon/co-surgeon team approach to avoid adverse outcomes. In those days, weekend courses proliferated and surgeons came back and started doing procedures with minimal experience. This explosive growth was driven by patient demands for this procedure. As anticipated, untoward outcomes were reported.

Effectiveness of strict credentialing and proctoring guidelines on outcomes of laparoscopic cholecystectomy in a community hospital.

UNLABELLED: Strict credentialing and proctoring guidelines were set up prior to initiating a program of laparoscopic cholecystectomy at the Good Samaritan Hospital in Downers Grove, Illinois. This is a private 386-bed community hospital. At the inception of the program, there were 15 general surgeons who were going to participate in this program. In 1992, there were 20 general surgeons performing the laparoscopic cholecystectomy (LC). The following guidelines were approved by the Credentials Committee and authorized by the Executive Committee: A. Training: A SAGES-approved or equivalent course in LC, meeting or exceeding SAGES guidelines. B. Proctoring: Proctoring of 10 LC cases, prior to operating independently. C. Prevention of injuries: Two surgeons credentialed in LC to operate as a surgeon-cosurgeon team. D. EVALUATION: 100% concurrent review of all LC cases.

Credentialing, privileging, proctoring in the era of laparoscopic surgery, history of credentialing problems originating with laparoscopic surgery.

Laparoscopic surgery in the United States was revolutionized in 1989. Even though Semm had popularized laparoscopic surgery in the early nineteen eighties in Germany, it was the advent of Laparoscopic Cholecystectomy in 1989 that triggered the explosive training and eredentialing issues in laparoscopic surgery. In a letter to the editor of the American Journal of Surgery, in June 1990, the author had recommended the following for training courses: 1) the operators should have extensive hands-on experience in diagnostic laparoscopy prior to embarking on laparoscopic surgery; 2) hands-on training to develop hand-eye coordination using Berci-Sackier trainers; 3) extensive explanation on the use and abuse of video laparoscope and accessory instrumentation; 4) a minimum experience as prime operator in at least 3 pigs, each weighing 90-100 lbs., with experience as an assistant operator and camera operator in 6 more pigs, making a total of 9 pigs per participant. This letter was written with an intent that proper training of surgeons would take place. We advocated a surgeon/co-surgeon team approach, to avoid adverse outcomes. In those days, weekend courses proliferated and surgeons came back and started doing procedures with minimal experience. This explosive growth was driven by patient demands for this procedure. As anticipated, untoward outcomes were reported.

Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,604 cases.

Complications of laparoscopic cholecystectomy were evaluated by a survey of surgical department chairpersons at 4,292 US hospitals. The 77,604 cases were reported by 1,750 respondents. Laparotomy was required for treatment of a complication in 1.2% of patients. The mean rate of bile duct injury (exclusive of cystic duct) was 0.6% and was significantly lower at institutions that had performed more than 100 cases. Bile duct injuries were recognized postoperatively in half of the cases and most frequently required anastomotic repair. Intraoperative cholangiography was practiced selectively by 52% of the respondents and routinely by 31%. Bowel and vascular injuries, which occurred in 0.14% and 0.25% of cases, respectively, were the most lethal complications. Postoperative bile leak was recognized in 0.3% of patients, most commonly originating from the cystic duct. Eighteen of 33 postoperative deaths resulted from operative injury. These data demonstrate that laparoscopic cholecystectomy is associated with low rates of morbidity and mortality but a significant rate of bile duct injury.

Transanal endoscopic microsurgery.

Transanal endoscopic microsurgery (TEM) has emerged as a minimally invasive means of resecting rectal tumors. Developed in Germany and now being used with increasing frequency in the United States, TEM utilizes a 40-mm operating rectoscope, which is sealed with an airtight facepiece. Carbon dioxide is constantly infused, thereby distending the rectum and maintaining visibility. A variety of instruments, such as tissue graspers, a high-frequency knife, suction, and needle holders, are inserted through the facepiece. Adenomas that are small, large, or even circumferential, as well as selected carcinomas up to 24 cm, can be removed with TEM instrumentation. The optics provide sixfold magnification, and this, combined with the constantly distended operative field, allows for a precise excision of the tumor as well as closure of the wound. For lesions in the mid and upper rectum, TEM is an alternative to a transsacral or transabdominal approach, with subsequently shorter hospital stay and fewer complications.

Therapeutic laparoscopic suturing techniques.

With the introduction of the technique of Interventional laparoscopy, a new era of minimally invasive general surgery has begun. The well-established principles of general surgical technique have not been altered by this new technology. As the new laparoscopic technology has become available, intraabdominal laparoscopic suturing and ligating techniques have been developed. The authors have attempted to elucidate the techniques of endoligation, "Endoloop" application, endosuture placement, sling suture placement, and continuous suture placement in laparoscopic surgery.

Assessment of quality of care in laparoscopic cholecystectomy.

With the advent of laparoscopic cholecystectomy, assessment of data and its relationship to quality of care became important. The Mount Sinai Hospital Medical Center conducted a prospective survey in conjunction with the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) National Survey. In this survey, only two surgeons operated as surgeon and co-surgeon with an extremely small rate of complication. A national survey of chairpersons in surgery was designed at Rush Presbyterian St. Luke's Hospital, and 4300 chairpersons were mailed questionnaires to record complications of laparoscopic cholecystectomy. There were 36,232 patients and 3111 surgeons in the survey. The Southern Surgeons Club experience, as reported in New England Journal of Medicine, was reviewed. Because of the complexity of understanding the implications of the survey results, the authors have arrived at a simplified system of evaluating quality of care in laparoscopic cholecystectomy. In this system only three considerations are taken into account: (a) elective conversions to standard operation, (b) forced conversions (due to iatrogenic injuries), and (c) reoperation rate (delayed complication). It is hoped that data collection will be simplified and more meaningful.

Laparoscopic removal of a large colonic lipoma. Report of a case.

A 72-year-old white male was found to have a 6-cm submucosal mass at 35 cm on screening sigmoidoscopy. The lesion had all the characteristics of a submucosal lipoma. Instead of performing a laparotomy with its potential morbidity, the lesion was removed laparoscopically in its entirety without untoward operative sequelae. Laparoscopic techniques have had a profound impact on the treatment of patients with surgical disorders. This new technology can be applied to selected patients with colorectal diseases.

Studies on secretion of catecholamine evoked by caffeine from the isolated perfused rat adrenal gland.

The influence of caffeine on secretion of catecholamines (CA) was examined in the isolated perfused rat adrenal gland. Caffeine (0.3 mM) perfused into an adrenal vein of the gland produced a marked increase in secretion of CA. This secretory effect of CA evoked by perfusion of caffeine for one minute was considerably prolonged, lasting for more than 90 minutes. The tachyphylaxis to releasing effect of CA induced by caffeine was observed by repeated perfusion of this drug. The caffeine-evoked CA secretion was markedly inhibited by pretreatment with ouabain, trifluoperazine, TMB-8 and perfusion with calcium-free Krebs solution containing 5 mM EGTA, but was not affected by perfusion of calcium-free Krebs solution without other addition. CA secretion evoked by caffeine was not reduced significantly by pretreatment with chlorisondamine but after the first collection of perfusate for 3 min was clearly inhibited. Interestingly, the caffeine-evoked CA secretion was considerably potentiated by pretreatment with atropine or pirenzepine, but after the first collection for 3 min it was markedly decreased. These experimental results suggest that caffeine causes a marked increase in secretion of CA from the isolated perfused rat adrenal gland by an extracellular calcium-independent exocytotic mechanism. The secretory effect of caffeine may be mainly due to mobilization of calcium from an intracellular calcium pool in the rat chromaffin cells and partly due to stimulation of both muscarinic and nicotinic receptors.

Review of 300 consecutive laparoscopic cholecystectomies: development, evolution, and results.

The present paper reviews 300 laparoscopic cholecystectomies with intraoperative cholangiograms that were performed by the authors. The development and evolution of this procedure are described along with the results. The guidewire technique used for operative cholangiography and the maneuver applied to control bleeding of the cystic artery are detailed. Five cases were converted to open operations. No serious complications were encountered. One common bile duct injury occurred during endoscopic retrograde cholangiopancreaticography performed on postoperative day 8 for diagnostic purposes.

[Discrete and continuous mathematical models of intraspecific behavior in the pharmacoethology of the mouse]. / Diskretnaia i nepreryvnaia matematicheskie modeli vnutrividovogo povedeniia v farmakoétologii myshei.

An algorithm and software library were compiled in order to interpret the intraspecies agonistic animal behaviour in terms of discrete or continuous mathematical model. Applied aspects of the use of mathematical models in pharmacoethology were shown on concrete examples. The ways of construction of standard prototypes, and the integrative criteria of psychotropic drugs action were developed. The possibility was shown of identification of unknown substances by comparing with standard drugs by calculating the norm of standardized matrices.