Mitral valve replacement is a cardiac surgery procedure in which a patient’s mitral valve is replaced by a different valve. Mitral valve replacement is typically performed robotically or manually, when the valve becomes too tight (mitral valve stenosis) for blood to flow into the left ventricle, or too loose (mitral valve regurgitation) in which case blood can leak into the left atrium and back up into the lung[1]. Some individuals have a combination of mitral valve stenosis and mitral valve regurgitation or simply one or the other.
A mitral valve replacement/repair is performed to treat severe cases of mitral valve prolapse, heart valve stenosis, or other valvular diseases.[2] Since a mitral valve replacement is an open heart surgical procedure, it requires placing the patient on cardiopulmonary bypass to stop blood flow through the heart when it is opened up[1].
A mitral valve replacement is necessary when the valve doesn’t open or close completely. When the valve narrows or is stenotic the valve doesn’t let blood flow easily into the heart causing the blood to "back up" and pressure to build up in the lungs[3]. This is dangerous because when the leaflets in the valve don’t meet correctly, blood may leak backwards into the lungs each time the heart pumps. If blood leaks backwards, the heart has to pump harder in order to push the same amount of blood forward. This is known as volume overload. The heart may compensate for this overload for many months or even years but eventually the heart begins to fail and patients show symptoms of shortness of breath or fatigue[3].
Causes
Mitral valve problems are mainly due to simple wear and tear that causes part of the valve mechanism to fail. Rheumatic fever may also damage the mitral valve causing stenosis or regurgitation, and occasionally the mitral valve is damaged by infection or bacterial endocarditis. Coronary artery disease may also cause the mitral valve to leak[3]. Symptoms
Some symptoms experienced by patients who need mitral valve repair or replacement include: unusual sensations of feeling the heart beat; chest pain; difficulty breathing (especially after activity); fatigue; coughing; and shortness of breath while lying flat. These symptoms may develop slowly, or the patient may not have any symptoms at all.[4]
Options
Some surgeons will first recommend repairing the valve instead of replacement, but if the patient is not a good candidate then they must replace the valve.[5]
Many mitral valves can be repaired, especially if the leak is due to wear and tear. When the valve is too damaged to repair, the valve must be replaced with an artificial valve[6]. There are some advantages to repairing a mitral valve versus replacing it. Some of these advantages are; a lower mortality at the time of operation (1-2% for repair versus 6-8% for replacement), a significantly lower risk of stroke, and a lower rate of infection, improved long-term survival with mitral valve repair. Patients who receive a valve repair stay on the same survival curve as the normal population. A survival curve tends to be a graph of downward steps with the x-axis as time in months and the y-axis as percent still alive.[7] After mitral valve repair, blood thinners are not required, in contrast to the life-long requirement for blood thinners after mechanical mitral valve replacement[8].
Non-Surgical Options
Most patients can endure surgery without complications; however, there are some whose heart functions are too weak to withstand surgery. Non-surgical approaches to treat heart valve disease without surgery are divided into three categories: Clinical Practice treatment (this is used in every day clinical practice), Investigational treatment (current clinical studies that are underway), Early Development treatment (early stages of investigation).[9] Types of Valves
There are two primary types of artificial mitral valves -- a metal or mechanical valve and a tissue valve or biological valve.[10] The mechanical valves are made entirely from metal and pyrolytic carbon and last a lifetime[6]. With this valve, patients are required to take blood-thinning medications to prevent clotting. The tissue valve is made from animal tissues[6]. The tissue valve doesn’t require a patient to take blood thinners, but it only last 10 to 15 years.[10] The choice of which type to use should be made by you and your doctors taking the following into consideration: your age, medical condition, preferences with medication, lifestyle[11]. Details of the procedure
A mitral valve replacement procedure is performed under general anesthesia, which will keep the patient asleep during the whole surgery.[2] The preferred method is to first make an incision under the left breast rather than through the breastbone in the front of the chest, to get to the heart. After the heart is exposed, blood must be rerouted to a heart-lung machine (cardiopulmonary bypass)[12]. An incision is made in the left atrium to expose the mitral valve. The valve is then replaced with either a biological valve or mechanical valve. The heart is then closed with sutures[12]. The patient is then taken off the cardiopulmonary bypass and blood is allowed to flow into the coronary arteries. If the heart does not beat on its own, an electric shock is used to start it. Then the chest is closed up[12]. Risks
With mitral valve replacement surgery, there are risks such as bleeding, infection, or a complicated reaction to anesthesia[13]. Each risk is determined best with each patients own cardiologist and cardiothoracic surgeon. They will better know each individuals medical history and conditions. Risks depend on a patient’s age, general condition, specific medical conditions, and heart function[11].
Postoperative Complications/ Risks
A common postoperative complication with mitral valve surgery in a study involving 99 patients who had surgery for mitral regurgitation from January 1990 to June 1996 is atrial fibrillation. This occurred in 32% of patients. A common pulmonary complication is congestion necessitating prolonged use of oxygen. Other patients required prolonged ventilation of longer than 24 hours for conditions like pulmonary edema, ARDS, and pulmonary thromboemboli[14]. Nine patients had renal failure with six of them dying within 30 days after their operation. Five patients had permanent strokes, and nine patients were readmitted to the hospital within 30 days of their discharge[14].
Effectiveness
In a clinical study done of 99 patients who had mitral valve surgery for regurgitation from January 1990 to June 1996, long-term and short-term outcomes were evaluated. These evaluations included; mortality rate, clinical complications, readmissions, valve deterioration, reoperation, and health perception. Overall mortality was 4%, which included 3 operative deaths and 4 late deaths. Overall 5-year survival rate was 92%[14].
Condition after mitral valve replacement
After the surgery the patient is taken to a post-operative intensive care unit for monitoring. A respirator may be required for the first few hours or days after surgery. After a day, the patient should be able to sit up in bed. After two days, the patient may be taken out of the intensive care unit. Patients are usually discharged after about seven to ten days[12]. If the mitral valve replacement is successful, patients can expect to return to their regular condition or even better. Patients who have biological valve are prescribed blood thinners (Anticoagulation) with Coumadin for 6 weeks to 3 months postoperative, while patients with mechanical valves are prescribed blood thinners for the rest of their lives. These blood thinners are taken to prevent blood clots that can move to other parts of your body and cause serious medical problems, such as a heart attack. Blood thinners will not dissolve a blood clot but they prevent other clots from forming or prevent clots from becoming larger. [15] Once the patient’s wounds are healed they should have few, if any, restrictions from daily activities[16]. Patients are advised to walk or undertake other physical activities gradually to regain strength. Patients who have physically demanding jobs will have to wait a little longer than those who don’t. Patients are also restricted from driving a car for six weeks after the surgery[17]. Once a person has a mitral valve procedure, they are required to have prophylactic antibiotics as a preventative measure against infection whenever they have dental work done[18].
Depending on the method of surgery, some scarring will occur. If the breastbone is divided, the patient will have a long scar along the breast bone. If the heart is accessed from under the left breast there will be a smaller scar in the spot.
Endoscopic thoracic sympathectomy (ETS) is a surgical procedure where certain portions of the sympathetic nerve trunk are destroyed. ETS is used to treat hyperhidrosis, facial blushing, Raynaud's disease and Reflex Sympathetic Dystrophy. By far the most common complaint treated with ETS is palmar hyperhidrosis, or "sweaty palms". In this disorder, the palms may constantly shed so much sweat that the affected person is unable to handle paper, sign documents, keep clothes dry, or shake hands. The result is often social phobia so severe as to be disabling.
Sympathectomy refers to the destruction of tissue anywhere in either of the two sympathetic trunks, long chains of nerve ganglia lying along either side of the spine. Each trunk is broadly divided into three regions: cervical (up by the neck), thoracic (in the chest) and lumbar (in the lower back). The most common area targeted in sympathectomy is the upper thoracic region, that part of the sympathetic chain lying between the first and fifth thoracic vertebrae.
History
Sympathectomy developed in the mid-19th century, when it was learned that the autonomic nervous system runs to almost every organ, gland and muscle system in the body. It was surmised that these nerves play a role in how the body regulates many different body functions in response to changes in the environment, exercise and emotion.
The first sympathectomy was performed by Alexander in 1889.[citation needed] Since the sympathetic nervous system was well known to affect many body systems, the surgery was performed in attempts to treat many conditions, including idiocy, goitre, epilepsy, glaucoma, and angina pectoris. Thoracic sympathectomy has been indicated for hyperhidrosis (excessive sweating) since 1920, when Kotzareff showed it would cause anhidrosis (total inability to sweat) from the nipple line upwards.[1][not in citation given]
A lumbar sympathectomy was also developed and used to treat excessive sweating of the feet and other ailments, and typically resulted in impotence in men. Lumbar sympathectomy is still being offered as a treatment for plantar hyperhidrosis, or as a treatment for patients who have a bad outcome (extreme 'compensatory sweating') after thoracic sympathectomy for palmar hyperhidrosis or blushing; extensive sympathectomy risks hypotension.
Sympathectomy itself is relatively easy to perform; however, accessing the nerve tissue in the chest cavity by conventional surgical methods was difficult, painful, and spawned several different approaches. The posterior approach was developed in 1908, and required resection (sawing off) of ribs.[citation needed] A supraclavical (above the collar-bone) approach was developed in 1935, which was less painful than the posterior, but was more prone to damaging important nerves and blood vessels.[citation needed]
Because of these difficulties, and because of disabling sequelae associated with sympathetic denervation, conventional or "open" sympathectomy was never a very popular procedure, although it continued to be practiced for hyperhidrosis, Raynaud's disease, and various psychiatric disorders. With the popularization of lobotomy in the 1940s, sympathectomy fell out of favor as a form of psychosurgery.
The endoscopic version of thoracic sympathectomy was pioneered by Goren Claes and Christer Drott in Sweden in the late 1980s. The development of endoscopic "minimally invasive" surgical techniques have made possible the mass-marketing of sympathectomy, and today ETS surgery is practiced in many countries throughout the industrial world. The total number of ETS surgeries performed worldwide to date numbers well over 100,000. This minimally invasive approach has its own dangers. During the surgery carbon-dioxide insufflation allows the collapse of the lung and access to the sympathetic chain. The use of carbon-dioxide has been associated with cardiovascular collapse.[2] Left, but not right, one-lung ventilation causes hypoxemia during endoscopic transthoracic sympathectomy,[3] and can have significant adverse effects on cardiopulmonary physiology,[4] and cause reduced perioperative arterial oxygen saturation.[5]
In addition to hyperhidrosis and Raynaud's, the indications for ETS have expanded to include facial blushing, and, once again, psychiatric disorders such as social phobia and agoraphobia. There are reports of ETS being used to achieve cerebral revascularization for patients with moyamoya disease [6] to treat headaches, - although there are reports of headache after cervical sympathectomy[7][8] - hyperactive bronchial tubes,[9] Long QT syndrome[10][11][12] Arrythmias and other symptathetic disorders. The surgery also has a Beta blocker effect on the heart,[1][2] and can suppress baroreflex control of the heart rate in patients with essential hyperhidrosis.[3]
From Dr Lin's website: A certain percentage of Angina, Reflex sympathetic dystrophy and pain, Raynaud’s syndrome, Asthma, Schizophrenia, Social phobia, Rhinitis, Migraine, Tremor disorders, Parkinsonism … can be treated by sympathetic surgery.
Dr Lin also treats addiction and alcoholism with this procedure.[13]
In the mid 1990s a group of Swedish ETS patients complaining of disabling side effects formed the organization FFSO (people disabled by sympathectomy). The group grew to over 300 members and their work led to the procedure being banned. The two surgeons who pioneered the technique, Drott and Claes, moved their practice from Sweden. They still perform the surgery.
Overview
Sympathectomy involves division of adrenergic, cholinergic and sensory fibers which elaborate adrenergic substances during the process of regulating visceral function.[14] It involves dissection of the main Sympathetic trunk in the upper thoracic region of the sympathetic nervous system, thus interrupting neural messages that ordinarily would travel to many different organs, glands and muscles. It is via these nerves of the autonomic nervous system that the brain is able to make adjustments in the body in response to changing conditions in the environment, changing emotional states, level of exercise, and other factors to maintain the body's homeostasis.
When performed endoscopically, the surgeon penetrates the chest cavity, making holes about the diameter of a straw between ribs. This allows the surgeon to insert the video camera in one hole and a surgical instrument in another.
Sympathectomy is accomplished by dissecting the nerve tissue of the main sympathetic chain. The clamping method, also referred to as ESB (Endoscopic Sympathetic Blockade) employs titanium clamps around the nerve tissue, and was developed in an attempt to make the procedure reversible. However, reversal of the clamping procedure has a short time window (a few days or weeks at most) and may be incomplete. There has been no independent study done into the reversibility of the procedure and many doctors maintain that the clamping method causes the same damage to the nerve, as the nerve tissue dies under the clamps within 24 hours, making it as irreversible as the cutting method.
It has been proposed that ETS can alter many bodily functions, including vascular responses [15] sweating,[1] heart rate,[16][17] heart stroke volume, [18][19] thyroid, baroreflex,[20]lung volume,[21][19] pupil dilation, skin temperature, goose bumps and other aspects of the autonomic nervous system, like the fight-or-flight response. It has been proposed, that it can also diminish the body's physical reaction to exercise [22][1][19] and possibly reactions to strong emotion by reducing sympathetic input to the heart (and thus is considered psychiatric surgery). In rare cases sexual function or digestion may be modified as well. [4][23][unreliable source?]
Some patients have required an artificial pacemaker after developing bradycardia as a side effect of the surgery.[24][25][26]
Results
The most common indication for ETS surgery is hyperhidrosis, or excessive sweating. However, the only empirical study on sweat before and after ETS demonstrated that the procedure increases total body sweating. [27]
Swedish National Board of Health and Welfare statement on treatment results says (English translation here, the original Swedish text here): "A large amount of international studies shows that an incision on the sympatikotomi nerve gives a very positive result when it come to hand perspiration and also that the side effects are rare.". Critics have raised serious questions about the methodology of such studies. It is interesting to note, that there has been no independent study into the effectiveness of safety of the ETS procedure. The systematic reviews that have been done only included articles published by the surgeons who perform the surgery, although a large number of articles has been published in the medical journals that investigate different effects and the changes following sympathectomy.
A news release published by John Wiley & Sons on the 5th of February 2004: "Lifestyle' Surgical Procedure Carries Unrecognized Risk of Complications".[5]
Sympathectomy works by disabling part of the autonomic nervous system, by surgically destroying it, and disrupting the signals to the brain. Many non-ETS doctors find this to be disturbing, as symptoms of the ANS dysfunction go further than the disabled thermoregulation. Sympathectomy prevents the occurrence of a variety of bodily changes, and hence, prevents sensory feedback of those changes (see Cervero & Sharkley, 1985).[28]
Exact results of ETS are impossible to predict, because of considerable anatomic variations in sympathetic nerve function from one patient to the next, and also because of variations in surgical technique. The autonomic nervous system is not anatomically exact and connections might exist with different parts of the body. This theory has been proven by the fact that a significant number of patients who have had sympathectomy for hand sweating might notice a reduction or elimination of feet sweating.
Studies by ETS surgeons have claimed an initial satisfaction rate around 85-95% with at least 2%-19% regretting the surgery and up to 51% of the patients complaining about decreased quality of life.[29][30][31][32] One study shows a satisfaction rate as low as 28.6.[33] Most patients report various adverse reactions as a result of the surgery. However, ETS surgeon Samuel S. Ahn of UCLA claims "100% success with no negative side effects". [34]
A large study of psychiatric patients treated with this surgery showed significant reductions in fear,alertness and arousal. (Teleranta, Pohjavaara, et al 2003, 2004). Arousal is essential to consciousness, in regulating attention and information processing, memory and emotion. [35] This study also proves what many patients have claimed, that the surgery caused psychological changes. You can not reduce 'bad' emotional responses, like fear or anxiety. If you reduce emotional responses, they will affect the whole range of emotions and their intensity. With the elimination of the heart rate variability, emotions are also 'capped'.[36] visceral and autonomic functions and were the key to understanding emotional processes. Paul D. MacLean believed that emotional experience could be most accurately described as a response to the composite of stimuli the brain receives from the external environment, as a result of ongoing perceptions of the outside world, and internal sensations or feedback transmitted to the brain from bodily organs and systems.
Galen, James..., [and] Cannon...are all saved; visceral [bodily] processes are the basis of emotion; and an identifiable part of the brain is responsible for emotional control and experience because of its selective relations with viscera...The path from the “emotions in the vascular system” to “emotions in the forebrain” had finally been completed, and each step along the way freed us from preconceptions popularly current when the step was taken.(Pribram KH. Emotions: A neurobehavioral analysis, p. 16)
ETS patients are being studied using the autonomic failure protocol headed by David Goldstein, M.D. Ph.D., senior investigator at the U.S National Institute of Neurological Disorders and Stroke. He has documented loss of thermoregulatory function, cardiac denervation, and loss of vasoconstriction.[37] Recurrence of the original symptoms due to nerve regeneration or nerve sprouting can occur within the first year post surgery, but regeneration can start years after sympathectomy. Nerve sprouting, or abnormal nerve growth after damage or injury to the nerves can cause other further damage. Sprouting sympathtetic nerves can form connections with sensory nerves, and lead to pain conditions that are mediated by the SNS. Every time the system is activated, it is translated into pain. This sprouting and it's action can lead to Frey's syndrome, a well recognized after effect of sympathectomy, when the growing sympathetic nerves innervate salivary glands. This leads to excessive sweating when eating. For patients different tastes can trigger this abnormal facial sweating (curiously this happens in the area where people who have undergone this procedure can not sweat any more normally). For some it only occurs with hot food, for others, with hot, sour - even by eating an apple, or sweet. Smelling can also cause abnormal reactions, as the signals get mixed up. Nerve regeneration and subsequent abnormal synapses is a well-documented phenomena.
Risks and controversy
Bleeding during and following the operation may be significant in up to 5% of patients.[38] Pneumothorax (collapsed lung) can occur (2% of patients).[38] Compensatory hyperhidrosis (sweating) is common over the long term, causing 1-2 percent of patients in one review to regret having had the surgery.[38]
A systematic review of the literature by Andrea D. Furlan, Angela Mailis, and Marios Papagapiou concluded: In these studies, 26.3% of patients with compensatory hyperhidrosis considered the complication major and disabling.[6]
The Finnish Office for Health Care Technology Assessment concluded in a 40 page systematic review that Endoscopic Thoracic Sympathectomy is associated with significant immediate and long-term adverse effects.[39]
Quoting the aforementioned (see Results) Swedish National Board of Health and Welfare statement: "The method can give permanent side effects that in some cases first will become obvious after some time. One of the side effects might be increased perspiration on different places on your body. Why and how this happens is still unknown. According to the research available about 25-75% of all patients can expect more or less serious perspiration on different places on their body, such as the trunk and groin area, this is Compensatory sweating. However, it is also mentioned in the research that 0-10% regrets having the surgery done for this reason. Other documented side effects are the inability to raise the heart rate when working out physically. This has in some cases led to decreased ability to perform your work and daily activities. Some patients also complained of not being able to control their body temperature and it is experienced from being very uncomfortable to disabling. However description of a changing sweating pattern does not give a comprehensive picture of the permanently disabled thermoregulation. Consequences of this go far beyond some discomfort wearing damp, in some cases dripping clothes and showing up in public.
A reduced efficiency in maintaining normal body temperature in warm environments is consistent with the reduced ability or complete inability to sweat above the nipple line, a common ETS outcome first shown by Dr. Kotzareff. For a fully clothed person, only the hands, cranial region and neck are typically exposed. In a hot environment, a normal person's body is cooled primarily by evaporation of water vapor through the warmest areas of exposed skin. These areas are associated with the head and neck, which under very warm circumstances or vigorous exercise, visibly show moisture (sweat) accumulating as part of the cooling process. For an ETS patient that has lost ability to sweat from cranium, neck, and arms, an increased amount of body heat must be rejected via transpiration/sweating involving skin of the lower body. Unfortunately, this skin is generally at a lower temperature and usually covered by clothing - both factors that reduce the cooling efficiency and result in poor thermoregulation. An uncomfortably warm sensation and accumulation of sweat on large areas of skin underneath clothing can result. This is one theory on the aetiology of the increased sweating phenomenon after sympathectomy. However one of the pioneers of the procedure, Dr Lin, who performed over 7000 procedures, disputes the compensatory nature of the so called Compensatory Sweating. According to him this is a result of the dysregulated thermoregulation and hypothalamus. He objects to using the "Compensatory" term, he sees as misleading. Postoperative sweating phenomenon is a reflex response between sympathetic system and Hypothalamus. "It is absolutely not a compensatory mechanism. The term of “Reflex sweating” instead of compensatory sweating is used. Hypothalamus is the center of Autonomic Nervous System, which influences human mind, mentality and endocrine system. For this sake, Dr. Lin emphasized, “Endoscopic Sympathetic Surgery helps us open a gate to Autonomic Nervous System”.
There is much disagreement among ETS surgeons about the best surgical method, optimal location for nerve dissection, and as to the nature and extent of the consequent primary effects and side effects. The internet now features many websites run by surgeons extolling the benefits of ETS backed by patient testimonials. However, there are also many websites run by disabled ETS victims who complain of severe adverse reactions and lack of adequate informed consent. Several online discussion forums are dedicated to the subject of ETS surgery, where both positive and negative patient testimonials abound, but considering that this is an elective surgery for a benign condition, even a small number of badly affected number of patients is a high number.
In 2003, ETS was banned in its birthplace, Sweden, due to overwhelming complaints by disabled patients. In 2004, Taiwanese health authorities banned the procedure on patients under 20 years of age. In other countries it is highly unregulated procedure. Although it was never evaluated for safety and adverse effects, sympathectomy is listed on Medical Benefits Scheme, and is freely available to public patients.
In 2006, the FinOHTA group, the Finnish Office for Health Technology Assessment, showed in a review that there were strong indications of side effects as a result of this surgery.[40]
• No systematic reviews, meta-analyses, or clinical trials that evaluated the effectiveness of endoscopic thoracic sympathectomy for treating facial blushing were identified. However, we have identified four case series related to the request (Drott et al. 1998, Rex et al. 1998, Telaranta 1998, Yilmaz et al. 1996). These studies were conducted in three countries (Sweden, Finland and the Netherlands).
• The four case series were not critically appraised because they are prone to bias and have significant methodological problems. These studies represent level IV evidence according to the NHMRC criteria and one should not draw firm conclusions from their findings.
• To date, the benefits or side effects associated with endoscopic thoracic sympathectomy for treating facial blushing have not been properly evaluated and reported. (Omar Ahmed PhD Centre for Clinical Effectiveness Monash Medical Centre Australia)
Other long term adverse effects: Ultrastructural Changes in the Cerebral Artery Wall Induced by Long-Term Sympathetic Denervation[26] Sympathectomy eliminates the psychogalvanic reflex[41] Cervical sympathectomy reduces the heterogeneity of oxygen saturation in small cerebrocortical veins[42] Sympathetic denervation is one of the causes of Mönckeberg's sclerosis[43] T2-3 sympathectomy suppressed baroreflex control of heart rate in the patients with palmar hyperhidrosis. We should note that baroreflex response for maintaining cardiovascular stability is suppressed in the patients who received the ETS.[20] ETS patients should be warned that these mechanisms may play a role in the development of exertional heat stroke.[1] Morphofunctional changes in the myocardium following sympathectomy.[44]
In none of the limbs studied after sympathectomy could an increase in blood flow be produced reflexly by warming; in the majority of instances the opposite response, a decrease in blood flow was observed. One patient with documented transection of the spinal cord above T5 behaved like subjects after surgical sympathectomy.[15] Retarded adaptation of hemodynamics to a sudden start of exercise after sympathectomy. The significant fall in left circumflex coronary flow was proportional to the decline in external heart work due to sympathectomy both at rest and under exercise.[22] Chemical sympathectomy is associated with increased pulmonary metastases.[45]
Popular culture
In the movie Sublime the character George Grieves (played by Tom Cavanagh) accidentally undergoes the procedure. The American TV show "Grey's Anatomy" featured ETS surgery for facial blushing in an episode titled "Make Me Lose Control". [46] In 'House' - Episode 3, Season 5 - A cardiac sympathectomy (a surgery that reduces the effect of the sympathetic nervous system on the heart) is ordered. The patient is told that the drawback might be that he actually will not FEEL it when he is having a heart attack.
Arthroscopy (also called arthroscopic surgery) is a minimally invasive surgical procedure in which an examination and sometimes treatment of damage of the interior of a joint is performed using an arthroscope, a type of endoscope that is inserted into the joint through a small incision. Arthroscopic procedures can be performed either to evaluate or to treat many orthopaedic conditions including torn floating cartilage, torn surface cartilage, ACL reconstruction, and trimming damaged cartilage.
The advantage of arthroscopy over traditional open surgery is that the joint does not have to be opened up fully. Instead, only two small incisions are made - one for the arthroscope and one for the surgical instruments. This reduces recovery time and may increase the rate of surgical success due to less trauma to the connective tissue. It is especially useful for professional athletes, who frequently injure knee joints and require fast healing time. There is also less scarring, because of the smaller incisions. Irrigation fluid is used to distend the joint and make a surgical space. Sometimes this fluid leaks into the surrounding soft tissue causing extravasation and edema [1]
The surgical instruments used are smaller than traditional instruments. Surgeons view the joint area on a video monitor, and can diagnose and repair torn joint tissue, such as ligaments and menisci or cartilage
Arthroscopy is used for joints of the knee, shoulder, elbow, wrist, ankle, foot, and hip.
Knee arthroscopy Lateral meniscus located between thigh bone (femur, above) and shin bone (tibia, below). The tibial cartilage displays a fissure (tip of teaser instrument).
Knee arthroscopy has in many cases replaced the classic arthrotomy that was performed in the past. Today knee arthroscopy is commonly performed for treating meniscus injury, reconstruction of the anterior cruciate ligament and for cartilage microfracturing. Arthroscopy can also be performed just for diagnosing and checking of the knee; however, the latter use has been mainly replaced by magnetic resonance imaging.
During an average knee arthroscopy, a small fiberoptic camera (the endoscope) is inserted into the joint through a small incision, about 4 mm (1/8 inch) long. A special fluid is used to visualize the joint parts. More incisions might be performed in order to check other parts of the knee. Then other miniature instruments are used and the surgery is performed.
Recovery after a knee arthroscopy is significantly faster as compared to arthrotomy. Most patients can return home and walk using crutches the same or the next day after the surgery. Recovery time depends on the reason that surgery was needed and the patient's physical condition. Usually a patient can fully load his leg within a couple of days and after a few weeks the joint function can fully recover. It is not uncommon for athletes who have an above average physical condition to return to normal athletic activities within a few weeks.
Arthroscopic surgeries of the knee are done for many reasons, but the usefulness of surgery for treating osteoarthritis is doubtful. A double-blind placebo-controlled study on arthroscopic surgery for osteoarthritis of the knee was published in the New England Journal of Medicine in 2002.[2] In this three-group study, 180 military veterans with osteoarthritis of the knee were randomly assigned to receive arthroscopic débridement with lavage, just arthroscopic lavage, or a sham surgery, which made superficial incisions to the skin while pretending to do the surgery. For two years after the surgeries, patients reported their pain levels and were evaluated for joint motion. Neither the patients nor the independent evaluators knew which patients had received which surgery. The study reported, "At no point did either of the intervention groups report less pain or better function than the placebo group."[3] Because there is no confirmed usefulness for these surgeries, many agencies are reconsidering paying for a surgery which seems to create risks with no benefit.[4] A 2008 study confirmed that there was no long-term benefit for chronic pain, above medication and physical therapy.[5] Since one of the main reasons for arthroscopy is to repair or trim a painful and torn or damaged meniscus, a recent study in the New England Journal of Medicine which shows that about 60% of these tears cause no pain and are found in asymptomatic subjects, may further call the rationale for this procedure into question.[6] Spinal arthroscopy
Many invasive spine procedures involve the removal of bone, muscle, and ligaments to access and treat problematic areas. In some cases, thoracic (mid-spine) conditions requires a surgeon to access the problem area through the rib cage, dramatically lengthening recovery time.
Arthroscopic (also endoscopic) spinal procedures allow a surgeon to access and treat a variety of spinal conditions with minimal damage to surrounding tissues. Recovery times are greatly reduced due to the relatively small size of incision(s) required, and many patients are treated on an outpatient basis.[7] Recovery rates and times vary according to condition severity and the patient's overall health. Arthroscopic procedures treat
* Spinal disc herniation and degenerative discs * spinal deformity * tumors * general spine trauma
Wrist arthroscopy Arthroscopic view showing two of the wrist bones.
Arthroscopy of the wrist is used to investigate and treat symptoms of repetitive strain injury, fractures of the wrist and torn or damaged ligaments. It can also be used to ascertain joint damage caused by arthritis.
History
Pioneering work in the field of arthroscopy began as early as the 1920s with the work of Eugen Bircher.[8] Bircher published several papers in the 1920s about his use of arthroscopy of the knee for diagnostic purposes.[8] After diagnosing torn tissue through arthroscopy, Bircher used open surgery to remove or repair the damaged tissue. Initially, he used an electric Jacobaeus thoracolaparoscope for his diagnostic procedures, which produced a dim view of the joint. Later, he developed a double-contrast approach to improve visibility.[9] Bircher gave up endoscopy in 1930, and his work was largely neglected for several decades.
While Bircher is often considered the inventor of arthroscopy of the knee,[10] the Japanese surgeon Masaki Watanabe, MD receives primary credit for using arthroscopy for interventional surgery.[11][12] Watanabe was inspired by the work and teaching of Dr Richard O'Connor. Later, Dr. Heshmat Shahriaree began experimenting with ways to excise fragments of menisci.[13]
The first operating arthroscope was jointly designed by these men, and they worked together to produce the first high-quality color intraarticular photography[14] The field benefited significantly from technological advances, particularly advances in flexible fiber optics during the 1970s and 1980s.
Fasciotomy is a surgical procedure where the fascia is cut to relieve tension or pressure (and treat the resulting loss of circulation to an area of tissue or muscle). Fasciotomy is a limb-saving procedure when used to treat acute compartment syndrome. It is also sometimes used to treat chronic compartment stress syndrome. The procedure has a very high rate of success, with the most common problem being accidental damage to a nearby nerve. Complications can also involve the formation of scar tissue after the operation. A thickening of the surgical scars can result in the loss of mobility of the joint involved. This can be addressed through occupational or physical therapy. Wound covered with a skin graft once pressure is relieved.
In addition to scar formation, there is a possibility that the surgeon may need to use a skin graft to close the wound. Sometimes when closing the fascia again in another surgical procedure, the muscle is still too large to close it completely. A small bulge is visible, but is not harmful.
Hemispherectomy is a surgical procedure where one cerebral hemisphere (half of the brain) is removed or disabled. This procedure is used to treat a variety of seizure disorders where the source of the epilepsy is localized to a broad area of a single hemisphere of the brain. It is solely reserved for extreme cases in which the seizures have not responded to medications and other less invasive surgeries.
History and changes
Hemispherectomy was first tried on a dog in 1888 by Friedrich Goltz. The first such operation on humans was done by Walter Dandy in 1923. In the 1960s and early 1970s, hemispherectomy involved removing half of the brain, but this resulted in unacceptable complications and side effects in many cases, like filling of excessive body fluids in the skull and pressuring the remaining lobe (known as hydrocephalus). The first successful operation was done by Dr. Ben Carson at world renown The Johns Hopkins Hospital. Today, the functional hemispherectomy has largely replaced this procedure, in which only the temporal lobe is removed; a procedure known as corpus callosotomy is performed; and the frontal and occipital lobes disconnected.
Results
All hemispherectomy patients suffer at least partial hemiplegia on the side of the body opposite the removed or disabled portion, and may suffer problems with their vision as well.
This procedure is almost exclusively performed in children because their brains generally display more neuroplasticity, allowing neurons from the remaining hemisphere to take over the tasks from the lost hemisphere. This likely occurs by strengthening neural connections which already exist on the unaffected side but which would have otherwise remained small in a normally functioning, uninjured brain.[1] One case, demonstrated by Smith & Sugar, 1975; A. Smith 1987, demonstrated that one patient with this procedure had completed college, attended graduate school and scored above average on intelligence tests. Studies have found no significant long-term effects on memory, personality, or humor after the procedure[2], and minimal changes in cognitive function overall.[3] Generally, the greater the intellectual capacity of the patient prior to surgery, the greater the decline in function. Most patients end up with mild to severe mental retardation, which is usually already present before surgery. When resectioning the left hemisphere, evidence indicates that some advanced language functions (i.e., higher order grammar) cannot be entirely assumed by the right side. The extent of advanced language loss is often dependent on the patient's age at the time of surgery.[4]
Foundations
The Hemispherectomy Foundation was formed in 2008 to assist families with children undergoing this procedure.
Bone marrow examination refers to the pathologic analysis of samples of bone marrow obtained by bone marrow biopsy (often called a trephine biopsy) and bone marrow aspiration. Bone marrow examination is used in the diagnosis of a number of conditions, including leukemia, multiple myeloma, anemia, and pancytopenia. The bone marrow produces the cellular elements of the blood, including platelets, red blood cells and white blood cells. While much information can be gleaned by testing the blood itself (drawn from a vein by phlebotomy), it is sometimes necessary to examine the source of the blood cells in the bone marrow to obtain more information on hematopoiesis; this is the role of bone marrow aspiration and biopsy.
Components of the procedure A bone marrow harvest. A volunteer donating bone marrow for scientific research.
Bone marrow samples can be obtained by aspiration and trephine biopsy. Sometimes, a bone marrow examination will include both an aspirate and a biopsy. The aspirate yields semi-liquid bone marrow, which can be examined by a pathologist under a light microscope as well as analyzed by flow cytometry, chromosome analysis, or polymerase chain reaction (PCR). Frequently, a trephine biopsy is also obtained, which yields a narrow, cylindrically shaped solid piece of bone marrow, 2mm wide and 2cm long (60 μL), which is examined microscopically (sometimes with the aid of immunohistochemistry) for cellularity and infiltrative processes. An aspiration, using a 20 mL syringe, yields approximately 300 μL of bone marrow.[1] A volume greater than 300 μL is not recommended, since it may dilute the sample with peripheral blood.[1]
Comparison Aspiration Biopsy Advantages
* Fast * Gives relative quantity of different cell types * Gives material to further study, e.g. molecular genetics and flow cytometry
* Gives cell and stroma constitution * Represents all cells * Explains cause of "dry tap" (aspiration gives no blood cells)
Drawbacks Doesn't represent all cells Slow processing
Aspiration doesn't always represent all cells since, as some such as lymphoma stick to the trabecula, and would thus be missed by a simple aspiration.
Site of procedure
Bone marrow aspiration and trephine biopsy are usually performed on the back of the hipbone, or posterior iliac crest. However, an aspirate can also be obtained from the sternum (breastbone). A trephine biopsy should never be performed on the sternum, due to the risk of injury to blood vessels, lungs or the heart.
How the test is performed
A needle used for bone marrow aspiration, with removable stylet.
A bone marrow biopsy may be done in a health care provider's office or in a hospital. Informed consent for the procedure is typically required. The patient is asked to lie on his or her abdomen (prone position) or on his/her side (lateral decubitus position). The skin is cleansed, and a local anesthetic such as lidocaine is injected to numb the area. Patients may also be pretreated with analgesics and/or anti-anxiety medications, although this is not a routine practice.
Typically, the aspirate is performed first. An aspirate needle is inserted through the skin until it abuts the bone. Then, with a twisting motion, the needle is advanced through the bony cortex (the hard outer layer of the bone) and into the marrow cavity. Once the needle is in the marrow cavity, a syringe is attached and used to aspirate ("suck out") liquid bone marrow. A twisting motion is performed during the aspiration to avoid excess content of blood in the sample, which might be the case if an excessively large sample from one single point is taken.
Subsequently, the biopsy is performed if indicated. A different, larger trephine needle is inserted and anchored in the bony cortex. The needle is then advanced with a twisting motion and rotated to obtain a solid piece of bone marrow. This piece is then removed along with the needle. The entire procedure, once preparation is complete, typically takes 10-15 minutes.
If several samples are taken, the needle is removed between the samples to avoid blood coagulation. After the procedure
After the procedure is complete, the patient is typically asked to lie flat for 5-10 minutes to provide pressure over the procedure site. After that, assuming no bleeding is observed, the patient can get up and go about their normal activities. Paracetamol (acetaminophen) or other simple analgesics can be used to ease soreness, which is common for 2-3 days after the procedure. Any worsening pain, redness, fever, bleeding or swelling may suggest a complication. Patients are also advised to avoid washing the procedure site for at least 24 hours after the procedure is completed.
Contraindications
There are few contraindications to bone marrow examination. The only absolute reason to avoid performing a bone marrow examination is the presence of a severe bleeding disorder which may lead to serious bleeding after the procedure. If there is a skin or soft tissue infection over the hip, a different site should be chosen for bone marrow examination. Bone marrow aspiration and biopsy can be safely performed even in the setting of extreme thrombocytopenia (low platelet count).
Complications
While mild soreness lasting 12-24 hours is common after a bone marrow examination, serious complications are extremely rare. In a large review, an estimated 55,000 bone marrow examinations were performed, with 26 serious adverse events (0.05%), including one fatality.[2] The same author collected data on over 19,000 bone marrow examinations performed in the United Kingdom in 2003, and found 16 adverse events (0.08% of total procedures), the most common of which was bleeding. In this report, complications, while rare, were serious in individual cases
Laryngectomy is the removal of the larynx and separation of the airway from the mouth, nose, and esophagus. The laryngectomee breathes through an opening in the neck, a stoma.[1] It is done in cases of laryngeal cancer. However, many laryngeal cancer cases are now treated only with radiation and chemotherapy or other laser procedures, and laryngectomy is performed when those treatments fail to conserve the larynx.
Voice replacement
* Voice functions are generally replaced with a voice prosthesis placed in the tracheo esophageal puncture created by the surgeon. The voice prosthesis vibrates the esophageal tissue in lieu of the larynx.
* A second method is the use of an electrolarynx. An electrolarynx is an external device that is placed against the neck and creates vibration that the speaker then articulates. The sound has been characterized as mechanical and robotic.
* A third method is called esophageal speech. The speaker pushes air into the esophagus and then pushes it back up, articulating speech sounds to speak. This method is time-consuming and difficult to learn and is seldom used by laryngectomees.
Uses
Laryngectomies number about 60,000 in the United States. Perhaps 10,000 laryngeal cancer cases are treated annually, but only about 3,000 people are laryngectomized. Because it is a relatively rare cancer and because the post-operative care is complex in achieving a functional result, laryngeal cancer patients should be treated at or at least consult a major federally designated cancer center, where the fields of surgery, radiology, chemotherapy, speech-language pathology are integrated in head and neck departments.
A hysterectomy (from Greek ὑστέρα hystera "womb" and εκτομία ektomia "a cutting out of") is the surgical removal of the uterus, usually performed by a gynecologist. Hysterectomy may be total (removing the body, fundus, and cervix of the uterus; often called "complete") or partial (removal of the uterine body but leaving the cervical stump, also called "supracervical"). It is the most commonly performed gynecological surgical procedure. In 2003, over 600,000 hysterectomies were performed in the United States alone, of which over 90% were performed for benign conditions.[1] Such rates being highest in the industrialized world has led to the major controversy that hysterectomies are being largely performed for unwarranted and unnecessary reasons. [2]
Removal of the uterus renders the patient unable to bear children (as does removal of ovaries and fallopian tubes), and changes her hormonal levels considerably, so the surgery is normally recommended for only a few specific circumstances:
* Certain types of reproductive system cancers (uterine, cervical, ovarian) or tumors * As a prophylactic treatment for those with either a strong family history of reproductive system cancers (especially breast cancer in conjunction with BRCA1 or BRCA2 mutation) or as part of their recovery from such cancers * Severe and intractable endometriosis (overgrowth of the uterine lining) and/or adenomyosis (a more severe form of endometriosis, where the uterine lining has grown into and sometimes through the uterine wall) after pharmaceutical and other non-surgical options have been exhausted * Postpartum to remove either a severe case of placenta praevia (a placenta that has either formed over or inside the birth canal) or placenta accreta (a placenta that has grown into and through the wall of the uterus to attach itself to other organs), as well as a last resort in case of excessive postpartum bleeding * For transmen, as part of their gender transition * For severe developmental disabilities
Although hysterectomy is frequently performed for fibroids (benign tumor-like growths inside the uterus itself made up of muscle and connective tissue), conservative options in treatment are available by doctors who are trained and skilled at alternatives. It is well documented in medical literature that myomectomy, surgical removal of fibroids with reconstruction of the uterus, has been performed for over a century.[specify]
The uterus is a hormone-responsive reproductive sex organ, and the ovaries produce the majority of estrogen and progesterone that is available in genetic females of reproductive age.
Some women's health education groups such as the Hysterectomy Educational Resources and Services (HERS) Foundation seek to inform the public about the many consequences and alternatives to hysterectomy, and the important functions that the female organs have all throughout a woman's life. [3][4] [5]
Incidence
According to the National Center for Health Statistics, of the 617,000 hysterectomies performed in 2004, 73% also involved the surgical removal of the ovaries. In the United States, 1/3 of genetic females can be expected to have a hysterectomy by age 60.[6] There are currently an estimated 22 million people in the United States who have undergone this procedure. An average of 622,000 hysterectomies a year have been performed for the past decade.[6]
In the UK, one in 5 women is likely to have a hysterectomy by age 60, and ovaries are removed in about 20% of hysterectomies.[7] Indications
Hysterectomy is usually performed for problems with the uterus itself or problems with the entire female reproductive complex. Some of the conditions treated by hysterectomy include uterine fibroids (myomas), endometriosis (growth of menstrual tissue outside of the uterine cavity), adenomyosis (a more severe form of endometriosis, where the uterine lining has grown into and sometimes through the uterine wall), several forms of vaginal prolapse, heavy or abnormal menstrual bleeding, and at least three forms of cancer (uterine, advanced cervical, ovarian). Hysterectomy is also a surgical last resort in uncontrollable postpartum obstetrical haemorrhage.[8]
Uterine fibroids, although a benign disease, may cause heavy menstrual flow and discomfort to some of those with the condition. Many alternative treatments are available: pharmaceutical options (the use of NSAIDs or opiates for the pain and hormones to suppress the menstrual cycle); myomectomy (removal of uterine fibroids while leaving the uterus intact); uterine artery embolization, high intensity focused ultrasound or watchful waiting. In mild cases, no treatment is necessary. If the fibroids are inside the lining of the uterus (submucosal), and are smaller than 4cm, hysteroscopic removal is an option. A submucosal fibroid larger than 4cm, and fibroids located in other parts of the uterus, can be removed with a laparotomic myomectomy, where a horizontal incision is made above the pubic bone for better access to the uterus.
Technique
Hysterectomy can be performed in different ways. Traditionally, it has been performed via either abdominal incision (total abdominal hysterectomy, or TAH, via laparotomy) or vaginal canal (vaginal hysterectomy). However, the vaginal route cannot be used if the "supracervical" procedure is desired. With the development of the laparoscopic techniques in the 1970-1980s, the "laparoscopic-assisted vaginal hysterectomy" (LAVH) has gained great popularity among gynecologists because the procedure is much less invasive and the post-operative recovery is much faster with fewer complications. LAVH is performed such that the final removal of the uterus (with or without removal of the ovaries) was via the vaginal canal. Thus, LAVH is also a total hysterectomy, namely, the cervix must be removed with the uterus. The "laparoscopic-assisted supracervical hysterectomy" (LASH) was later developed to remove the uterus without removing the cervix using a morcellator which cuts the uterus into small pieces that can be removed from the abdominal cavity via the laparoscopic ports. For large multifibroid uteri total laparoscopic hysterectomy can be performed with the use of in situ morcellation by gynecologists who are experienced in laparoscopic techniques.[9]
Most hysterectomies in the United States and in most parts of the world are done via laparotomy. A transverse (Pfannenstiel) incision is made through the abdominal wall, usually above the pubic bone, as close to the upper hair line of the individual's lower pelvis as possible, similar to the incision made for a caesarean section. This technique allows doctors the greatest access to the reproductive structures and is normally done for removal of the entire reproductive complex. The recovery time for an open hysterectomy is 4–6 weeks and sometimes longer due to the need to cut through the abdominal wall. The open technique carries increased risk of hemorrhage due to the large blood supply in the pelvic region, as well as an increased risk of infection from the need to move intestines and bladder in order to reach the reproductive organs and to search for collateral damage from endometriosis or cancer. However, an open hysterectomy provides the most effective way to ensure complete removal of the reproductive system as well as providing a wide opening for visual inspection of the abdominal cavity.
Many women want to retain the cervix believing that it may affect sexual satisfaction after hysterectomy. It has been postulated, without data, that removing the cervix causes excessive neurologic and anatomic disruption, thus leading to vaginal shortening, vaginal vault prolapse, and vaginal cuff granulations. These issues were addressed in a systematic review of total versus supracervical hysterectomy for benign gynecological conditions, which reported the following findings[10]:
1. There was no difference in the rates of incontinence, constipation or measures of sexual function.
2. Length of surgery and amount of blood lost during surgery were significantly reduced during supracervical hysterectomy compared to total hysterectomy, but there was no difference in post-operative transfusion rates.
3. Febrile morbidity was less likely and ongoing cyclic vaginal bleeding one year after surgery was more likely after supracervical hysterectomy.
4. There was no difference in the rates of other complications, recovery from surgery, or readmission rates.
In the short-term, randomized trials have shown that cervical preservation or removal does not affect the rate of subsequent pelvic organ prolapse[11]. However, no trials to date have addressed the risk of pelvic organ prolapse many years after surgery, which may differ after total versus supracervical hysterectomy. It is obvious that supracervical hysterectomy does not eliminate the possibility of having cervical cancer since the cervix itself is left intact. Those who have undergone this procedure must still have regular Pap smears to check for cervical dysplasia or cancer.
Recent technological advancement introduced the robot-assisted laparoscopic hysterectomy into the practice of gynecology. It is essentially the same as the surgeon-operated laparoscopic hysterectomy, however, the robot-controlled laparoscopic system offers superior 3D visualization along with greatly enhanced dexterity, precision and control in an intuitive, ergonomic interface with breakthrough capabilities[12]. The major issue is the capital investment for the robot system, which can easily go beyond $1,000,000 per system.
A new technique called "Intrastromal Abdominal Hysterectomy" was recently developed aiming at sparing nerves, no blood loss and no disturbances to the pelvic support system[13]. A total of 40 women were placed in this prospectively randomized clinical trial of this procedure. The average age of the participating women was 50.6 years. Patients were randomized into two groups: the study group and the control group. In the study group (n=20), Intrastromal Abdominal Hysterectomy was performed, and in the control group (n=20), a conventional hysterectomy was performed. All operations were performed by the same surgeon in order to minimize any bias due to differences in surgical technique and style. The results showed that there are significant differences in favor of the study group in terms of the blood loss and short hospital stay.
Types of Hysterectomy:
* Radical hysterectomy : complete removal of the uterus, upper vagina, and parametrium * Subtotal hysterectomy : removal of the fundus of the uterus, leaving the cervix in situ * Total hysterectomy : Complete removal of the uterus including the corpus and cervix Benefits
Women with a risk of breast cancer, especially those with BRCA1 or BRCA2 gene mutations, have been shown to have a significantly reduced risk of developing breast cancer after prophylactic oophorectomy.[14] In addition, removal of the uterus in conjunction with prophylactic oophorectomy allows estrogen-only hormone replacement therapy (HRT) to be prescribed to aid the individual through their transition into surgical menopause, instead of estrogen-progestin HRT, which has a slightly increased risk of breast cancer as compared with post-menopausal non-hysterectomized women taking HRT.[15]
The Maine Women's Health Study of 1994 followed for 12 months time approximately 800 women with similar gynecological problems (pelvic pain, urinary incontinence due to uterine prolapse, severe endometriosis, excessive menstrual bleeding, large fibroids, painful intercourse), around half of whom had a hysterectomy and half of whom did not. The study found that a substantial number of those who had a hysterectomy had marked improvement in their symptoms following hysterectomy, as well as significant improvement in their overall physical and mental health one year out from their surgery. The study concluded that for those who have intractable gynecological problems that had not responded to non-surgical intervention, hysterectomy may be beneficial to their overall health and wellness.[16]
One of the conditions most cited by women who have complex pelvic and reproductive issues is pain[17]. This is particularly true for women who have other conditions that amplify pain, such as fibromyalgia and chronic fatigue syndrome. Removal of a condition that is causing pain has a dramatic effect on reducing the overall pain levels of a person with such disorders; for many women with such pain conditions, a hysterectomy is preferable to the continual pain which adds to the burden of their already painful lives, even though the loss of hormones post-surgery may initially contribute to an increase in the symptoms of their disorder[18]. Risks and side effects
The average onset age of menopause in those who underwent hysterectomy is 3.7 years earlier than average.[19] This has been suggested to be due to the disruption of blood supply to the ovaries after a hysterectomy. When the ovaries are also removed, blood estrogen levels fall, removing the protective effects of estrogen on the cardiovascular and skeletal systems. This condition is often referred to as "surgical menopause", although it is substantially different from a naturally-occurring menopausal state; the former is a sudden hormonal shock to the body that causes rapid onset of menopausal symptoms such as hot flashes, while the latter is a gradually occurring decrease of hormonal levels over a period of years with uterus intact and ovaries able to produce natural female hormones even after the cessation of menstrual periods.
When only the uterus is removed there is a three times greater risk of cardiovascular disease. If the ovaries are removed the risk is seven times greater. Several studies have found that osteoporosis (decrease in bone density) and increased risk of bone fractures are associated with hysterectomies.[20][21][22][23][24][25] This has been attributed to the modulatory effect of estrogen on calcium metabolism and the drop in serum estrogen levels after menopause can cause excessive loss of calcium leading to bone wasting.
Some women find their natural lubrication during sexual arousal is also reduced or eliminated. Those who experience uterine orgasm will not experience it if the uterus is removed. The vagina is shortened and made into a closed pocket and there is a loss of support to the bladder and bowel.[specify]
Those who have undergone a hysterectomy with both ovaries removed typically have reduced testosterone levels as compared to those left intact.[26] Reduced levels of testosterone in women is predictive of height loss, which may occur as a result of reduced bone density,[27] while increased testosterone levels in women are associated with a greater sense of sexual desire.[28] Hysterectomy has also been found to be associated with increased bladder function problems, such as urinary incontinence.[29]Hysterectomies have also been linked with higher rates of heart disease and weakened bones.[30]
Removal of the uterus without removing the ovaries can produce a situation that on rare occasions can result in ectopic pregnancy due to an undetected fertilization that had yet to descend into the uterus before surgery. Two cases have been identified and profiled in an issue of the Blackwell Journal of Obstetrics and Gynecology; over 20 other cases have been discussed in additional medical literature.[31] Alternatives
Many alternatives to hysterectomy exist. Those with dysfunctional uterine bleeding (DUB) may be treated with endometrial ablation, which is an outpatient procedure in which the lining of the uterus is destroyed with heat. Endometrial ablation will greatly reduce or entirely eliminate monthly bleeding in ninety percent of patients with DUB. In addition, uterine fibroids may be removed and the uterus reconstructed. This procedure is called a "myomectomy." A myomectomy may be performed through an open incision or, in appropriate cases, laparoscopically.[32] Various other techniques (such as uterine artery embolization, Myolysis, radio frequency ablation, and Focused Ultrasound Surgery) kill the fibroid, and then leave it in place to be (usually only partially) reabsorbed by the body. Prolapse may also be corrected surgically without removal of the uterus.[33]
Menorrhagia (heavy or abnormal menstrual bleeding) may also be treated with the less invasive endometrial ablation.[34]
Uterine artery embolization, this approach blocks the arteries that supply blood to uterus. It is a minimally-invasive procedure, which means it requires only a tiny nick in the skin, and is performed while the patient is conscious but sedated—drowsy and feeling no pain. It can be used to control bleeding in conditions like postpartum hemorrhage[35] and for treatment of uterine fibroids.
Embolization is performed by an interventional radiologist, a physician who is specially trained to perform this and other minimally-invasive procedures under radiological guidance. The radiologist makes a small nick in the skin (less than one-quarter of an inch) in the groin to access the femoral artery, and inserts a tiny tube (catheter-like a piece of spaghetti) into the artery. Local anesthesia is used so the needle puncture is not painful. The catheter is guided through artery to the uterus while the interventional radiologist guides the process of the procedure using a moving X-ray (fluoroscopy). However, it is also important to note that significant adverse effects resulting from uterine artery embolization have been reported in the medical literature[1] [2]. Death from embolism, or septicemia (the presence of pus-forming or other pathogenic organisms, or their toxins, in the blood or tissues) resulting in multiple organ failure.[36] Infection from tissue death of fibroids, leading to endometritis (infection of the uterus) resulting in lengthy hospitalization for administration of intravenous antibiotics. [37] Misembolization from microspheres or polyvinyl alcohol (PVA) particles flowing or drifting into organs or tissues where they were not intended to be, causing damage to other organs or other parts of the body. [38] Ovarian damage resulting from embolic material migrating to the ovaries. Loss of ovarian function, infertility[39], and loss of orgasm. Failure of embolization surgery- continued fibroid growth, regrowth within four months. Menopause - iatrogenic, abnormal, cessation of menstruation and follicle stimulating hormones elevated to menopausal levels. [40] Post-Embolization Syndrome (PES) - characterized by acute and/or chronic pain, temperatures of up to 102 degrees, malaise, nausea, vomiting and severe night sweats. Foul vaginal odor coming from infected, necrotic tissue which remains inside the uterus. Hysterectomy due to infection, pain or failure of embolization. [41] Severe, persistent pain, resulting in the need for morphine or synthetic narcotics. [42] Hematoma, blood clot at the incision site. Vaginal discharge containing pus and blood, bleeding from incision site, bleeding from vagina, fibroid expulsion (fibroids pushing out through the vagina), unsuccessful fibroid expulsion (fibroids trapped in the cervix causing infection and requiring surgical removal), life threatening allergic reaction to the contrast material, and uterine adhesions. Gender transitioning Main article: Sex reassignment surgery female-to-male
Hysterectomies with bilateral salpingo-oophorectomy are often performed either prior to or as a part of gender reassignment surgery for transmen. Some in the FTM community prefer to have this operation along with hormone replacement therapy in the early stages of their gender transition to avoid complications from heavy testosterone use while still having female-hormone-producing organs in place (e.g. uterine cancer and hormonally-induced coronary artery disease) or to remove as many sources of female sex hormones as possible in order to better "pass" during the real life experience portion of their transition.[43] Just as many, however, prefer to wait until they have full "bottom surgery" (removal of female sexual organs and construction of male-appearing external anatomy)[44] to avoid undergoing multiple separate operations.
In thoracic surgery, a pulmonary thromboendarterectomy, PTE, is an operation that removes organized clotted blood (thrombus) from the pulmonary arteries.
Indication
PTE is a treatment for chronic thromboembolic pulmonary hypertension (pulmonary hypertension induced by recurrent/chronic pulmonary emboli). Description of the surgery
A PTE has significant risk; mortality for the operation is typically 5%. PTEs are risky because what is done and how it is done. PTEs involve a full cardiopulmonary bypass (CPB), deep hypothermia and full cardiac arrest, with the critical procedure carried out in a standstill operation. [1]. The reason for the complexity of procedure comes from the anatomy. The obvious part is that a pulmonary bypass is required. Surgeons cannot operate on something they cannot see; the blood going to the lungs has to be diverted from the pulmonary vasculature and lung function taken care of by a machine. Less obvious is that hypothermia is required. This goes back to the pathophysiology of emboli; they are organized, somewhat delicate, essentially part of the vessel wall, and hard to remove completely, unlike in an acute pulmonary embolectomy (for acute pulmonary embolism, which is done without hypothermia).[2][3] Making this task more difficult is the anatomy of the lung and pathophysiology of chronic thromboembolic pulmonary hypertension (CTEPH); lungs also get blood from the bronchial arteries are often enlarged. The practical implication is that a conventional cardiopulmonary bypass (CPB) is not sufficient to do the surgery because
1. too much blood would be in the surgical field and 2. the delicate thrombi would be difficult to remove completely.
The solution is a full cardiac arrest, which can be done with hypothermia. So, after going on to CPB and they induce a deep hypothermia (18-20 degrees Celsius), to preserve the patient's brain. Once the patient is cooled off sufficiently the CPB machine is turned off and the surgeon has time to do the delicate work, which takes about 40 minutes, and consists of carefully removing the organized thrombus. The most challenging part of the surgery is finding the optimal plane to dissect the pulmonary artery. If the surgeon dissects too deeply into the vessel wall the pulmonary vessels may rupture. If the surgeon does not dissect deep enough the clot breaks proximally during extraction and the distal part of the pulmonary vasculture will not have its pulmonary blood flow restored. The right lung is typically done first as it is easier. Video cameras (angioscopes) are used to see deeper into the pulmonary vasculture. At the end an almost beautiful negative of the pulmonary arteries exists--as the emboli over time fill the larger vessels that feed the smaller occluded vessel. (Would be nice to have a picture of this). It is not uncommon that collectively this negative almost represents the whole pulmonary tree--the only part missing being what the person was living off before the surgery. Bypass time is typically 345 minutes.[4] Recovery/ICU
The ICU recovery involves several challenges. Most patients get significant reperfusion pulmonary edema, at places where thrombi were removed, [Levinson et al., 1986] and thus have less than ideal oxygen saturation values. This results because with the thrombus removal the surgeon strips out the pulmonary endothelium. The challenge for the ICU physician thus is getting the extra water out of the lungs, (for which they make use of the strong diuretic furosemide) to get decent oxygen saturation values, yet maintain the blood pressure. Maintaining these two parameters can be a challenge. Maintaining a good oxygen saturation can be accomplished by run the patient dry (with a diuretic) and set a high BiPAP (bidirectional positive airway pressure). Problem is that a high BiPAP leads to a poor venous return, which means the blood pressure suffers. Adding volume would help with the blood pressure, but would make the edema worse so it is generally avoided. Adding albumin does not help; the pulmonary arteries are too porous post-operation. So, a balancing act is required between blood pressure and oxygen saturation that is controlled with the BiPAP and the diuretic. Post-surgery
The benefits of PTEs are significant. Most patients after surgery no longer suffer from shortness of breath and therefore have a much improved quality of life. Further, pulmonary vascular resistance usually drops back to close normal levels. Since the pulmonary resistance is proportional to the pressure driving the pulmonary flow (P=Q*R), it follows that the pulmonary pressure decreases. This in turn means that the work per time (power) decreases because it is equal to the pressure gradient times the volumetric flow, which in this case is the cardiac output. As a result of the operation, patients are spared from pulmonary hypertension and further right ventricular hypertrophy. Most pleasing is that patients who previously had right heart dysfunction often recover function.[5] History and development
The UCSD Medical Center's cardiothoracic surgery department is widely recognized as a pioneer in the relatively new surgery, having performed more PTEs than the rest of the world combined (over 2100 since 1970) with the lowest mortality rate (less than 5%).[citation needed]
Relation to pulmonary thrombectomies
PTEs and pulmonary thrombectomies are both operations that removed thrombus from the lung's arterial vasculature. Aside from this similarity they differ in many ways.
* PTEs are done non-emergently whilst pulmonary thrombectomies are typically done as an emergency procedure. * PTEs typically are done using hypothermia and full cardiac arrest. * PTEs are done for chronic pulmonary embolism, thrombectomies for severe acute pulmonary embolism. * PTEs are generally considered a very effective treatment, surgical thrombectomies are an area of some controversy and their effectiveness a matter of some debate in the medical community.
VIDEO Note: Of a carotid endarterectomy. *No know video for Pulmonary thromboendarteacrectomy*
Nissen fundoplication is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatus hernia. In GERD it is usually performed when medical therapy has failed, but with paraesophageal hiatus hernia, it is the first-line procedure. Partial fundoplications known as a Dor fundoplication or Toupet fundoplication may accompany surgery for achalasia.
The procedure
In a fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the inferior part of the esophagus and stitched in place, reinforcing the closing function of the lower esophageal sphincter: Whenever the stomach contracts, it also closes off the esophagus instead of squeezing stomach acids into it. This prevents the reflux of gastric acid (in GERD). A fundoplication can also prevent hiatal hernia, in which the fundus slides up through the enlarged esophageal hiatus of the diaphragm.
In a Nissen fundoplication, also called a complete fundoplication, the fundus is wrapped all the way around the esophagus. In contrast, surgery for achalasia is generally accompanied by either a Dor or Toupet partial fundoplication, which is less likely than a Nissen wrap to aggravate the dysphagia that characterizes achalasia. In a Dor (anterior) fundoplication, the fundus is laid over the top of the esophagus; while in a Toupet (posterior) fundoplication, the fundus is wrapped around the back of the esophagus.
The procedure is often performed laparoscopically. Alternatively a much more invasive open proceedure may be warrented. When used to alleviate gastroesophageal reflux symptoms in patients with delayed gastric emptying, it is frequently combined with modification of the pylorus via pyloromyotomy or pyloroplasty.
Nissen fundoplication is generally considered to be safe and effective, with a mortality rate of less than 1%. Studies have shown that after 10 years, 89.5% of patients are still symptom-free.[1]
Other patiens have found a need to reverse the proceedure due to severe side effects. Many patients must have the surgery redone to adjust the tightnes of the band.
Fundoplication to correct hiatal hernia has shown to weaken the hiatus and increase the chance of a hernia reoccuring. Manipulative therapies often prove effective in the treatment of hiatal hernia. Complications
Complications include "gas bloat syndrome", dysphagia (trouble swallowing), dumping syndrome, excessive scarring, and rarely, achalasia.[2] The fundoplication can also come undone over time in about 5-10% of cases, leading to recurrence of symptoms. If the symptoms warrant a repeat surgery, the surgeon may use Marlex or another form of artificial mesh to strengthen the connection.[3]
In "gas bloat syndrome", patients report being unable to belch, leading to an accumulation of gas in the stomach or small intestine. This is said to occur in 2-5% of patients, depending on surgical technique, and is commonly believed to be related to the tightness of the "wrap". Most often, gas bloat syndrome is self-limiting within 2 to 4 weeks, but in some it may persist. The offending gas may come from dietary sources, especially carbonated beverages; another suspected cause is involuntary swallowing of air (aerophagia). If gas bloat syndrome occurs postoperatively and does not resolve with time, dietary restrictions, and counselling regarding aerophagia, it may be beneficial to consider treating the condition with an endoscopic balloon dilatation.[citation needed]
Vomiting is often difficult or even impossible with a fundoplication. In some cases, the purpose of this operation is to correct excessive vomiting. However, when its purpose is to reduce gastric reflux, difficulty in vomiting may be an undesired outcome. Initially, vomiting is impossible; however, small amounts of vomit may be produced after the wrap settles over time, and in extreme cases such as alcohol poisoning or food poisoning, the patient may be able to vomit freely.
Other complications include mood changes, joint and spinal chronic pain, vagus nerve damage, gastreoparis, cyclic vomiting syndrome, Schatzkis Ring, re-occurance or emergence of hiatal hernia, food allergies (esp wheat and red meat), IBS, Barrett's Esophagus, and an increased chance of cancer.
History
Dr. Rudolph Nissen first performed the procedure in 1955 and published the results of two cases in a 1956 Swiss Medical Weekly.[4] In 1961 he published a more detailed overview of the procedure.[5] Nissen originally called the surgery "gastroplication." The procedure has borne his name since it gained popularity in the 1970's.
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