PROCEDURE OF THE DAY
Lobotomy
A lobotomy (Greek: lobos: Lobe of brain, tomos: "cut/slice") is a neurosurgical procedure, a form of psychosurgery, also known as a leukotomy or leucotomy (from Greek leukos: clear or white and tomos meaning "cut/slice"). It consists of cutting the connections to and from the prefrontal cortex. Lobotomies have now fallen out of use, as doctors use various drugs and psychological therapies to treat mental health issues. Lobotomies were used mainly from the 1930s to 1950s to treat a wide range of severe mental illnesses, including schizophrenia, clinical depression, and various anxiety disorders, as well as people who were considered a nuisance by demonstrating behavior characterized as, for example, "moodiness" or "youthful defiance". The patient's informed consent in the modern sense was often not obtained. After the introduction of the antipsychotic chlorpromazine (Thorazine), lobotomies fell out of common use[1] and the procedure has since been characterized "as one of the most barbaric mistakes ever perpetrated by mainstream medicine".[2]
History
In 1890, psychiatrist Gottlieb Burckhardt removed pieces of the frontal lobes of six patients in a psychiatric hospital in Switzerland. One died after the operation, and another was found dead in a river 10 days after release (whether by accident, suicide, or crime is unknown).[citation needed] The others exhibited altered behavior.
These experiments marked one of the first forays into the field of psychosurgery. Burckhardt claimed a 50% success rate but didn't properly assess or follow-up, and his reports "made everyone feel ill at ease and encountered harsh comments from colleagues". Emil Kraepelin said "he suggested that restless patients could be pacified by scratching away the cerebral cortex".
Burckhardt wrote in 1891 that "Doctors are different by nature. One kind adheres to the old principle: first, do no harm (primum non nocere); the other one says: it is better to do something than do nothing (melius anceps remedium quam nullum). I certainly belong to the second category", but he ended his research and practice of psychosurgery due to the heavy criticism.[3]
Psychosurgery was not publicly attempted again until 1910, when Estonian neurosurgeon Ludvig Puusepp operated on a few patients. Then, in 1935, Portuguese physician and neurologist António Egas Moniz pioneered a surgery he called prefrontal leucotomy. The procedure involved drilling holes in the patient's head and destroying tissue in the frontal lobes by injecting alcohol. He later changed technique, using a surgical instrument called a leucotome that cut brain tissue by rotating a retractable wire loop (a quite different cutting instrument also used for lobotomies shares the same name).[4] Moniz was given the Nobel Prize for medicine in 1949 for this work.[5]
The American neurologist and psychiatrist Walter Freeman was intrigued by Moniz's work, and with the help of his close friend, a neurosurgeon named James W. Watts, he performed the first prefrontal leucotomy in the U.S. in 1936. Freeman and Watts gradually refined the surgical technique, and created the Freeman-Watts procedure (the "precision method," the standard prefrontal lobotomy).
The Freeman-Watts prefrontal lobotomy still required drilling holes in the scalp, so surgery had to be performed in an operating room by trained neurosurgeons. Walter Freeman believed this surgery would be unavailable to those he saw as needing it most: patients in state mental hospitals having no operating rooms, surgeons, or anesthesia, and limited budgets. Freeman wanted to simplify the procedure so that it could be carried out by psychiatrists in mental asylums, which housed roughly 600,000 American inpatients at the time.
Inspired by the work of Italian psychiatrist Amarro Fiamberti, Freeman decided to access the frontal lobes through the eye sockets, instead of through drilled holes in the scalp. In 1945, he took an icepick from his own kitchen and began to test the new surgical technique on cadavers. The technique was called "transorbital lobotomy," and it involved lifting the upper eyelid and placing the point of a thin surgical instrument (often called an orbitoclast or leucotome, although quite different from the wire loop leucotome described above) under the eyelid and against the top of the eyesocket. A hammer or mallet was then used to drive the leucotome through the thin layer of bone and into the brain. The leucotome was then moved from side to side, to sever the nerve fibers connecting the frontal lobes to the thalamus.
In selected patients, the butt of the leucotome was pulled upward, sending the tip farther back into the brain, producing a "deep frontal cut," a more radical form of lobotomy. The leucotome was then withdrawn, and the procedure was repeated on the other side. Walter Freeman first performed a transorbital lobotomy on a live patient in 1946. This new form of psychosurgery was intended for use in state mental hospitals that often did not have the facilities for anesthesia, so Freeman suggested using electroconvulsive therapy to render the patient unconscious.[6]
As early as 1944, an author in the Journal of Nervous and Mental Disease could remark that: "The history of prefrontal lobotomy has been brief and stormy. Its course has been dotted with both violent opposition and with slavish, unquestioning acceptance."
In 1947, Swedish psychiatrist Snorre Wohlfahrt evaluated early trials and reported that "It is distinctly hazardous to leucotomize schizophrenics", "It is still too imperfect to enable us, with its aid, to venture on a general offensive against chronic cases of mental disorder", and in 1949 that "Psychosurgery has as yet failed to discover its precise indications and contraindications and the methods must unfortunately still be regarded as rather crude and hazardous in many respects".[7]
In 1948, Norbert Wiener, the author of Cybernetics, said: "...prefrontal lobotomy ...has recently been having a certain vogue, probably not unconnected with the fact that it makes the custodial care of many patients easier. Let me remark in passing that killing them makes their custodial care still easier."[8]
Concerns about lobotomy steadily grew. The USSR banned the procedure in 1950.[9] Doctors in the Soviet Union concluded that the procedure was "contrary to the principles of humanity", and, that it turned "an insane person into an idiot".[10] Numerous countries subsequently banned the procedure, including Yugoslavia, Germany and Japan, as did several U.S. states. Lobotomy was legally practiced in controlled and regulated U.S. centers and in Finland, Sweden, Norway (2,005 known cases[11]), the United Kingdom, Spain, India, Belgium and the Netherlands.
In 1977, the U.S. Congress created a National Committee for the Protection of Human Subjects of Biomedical and Behavioral Research to investigate allegations that psychosurgery—including lobotomy techniques—was used to control minorities and restrain individual rights. It also investigated the after-effects of surgery. The committee concluded that some extremely limited and properly performed psychosurgery could have positive effects.
By the early 1970s the practice had generally ceased, but some countries continued small-scale operations through the late 1980s. According to a report by the International Graphoanalysis Society (IGAS), between 1980 and 1986 there were 70 lobotomies performed in Belgium, 32 in France, 15 per year in the United Kingdom and several cases performed for the Massachusetts General Hospital in Boston.
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Circumcision
PROCEDURE OF THE DAY
Circumcision
Male circumcision is the removal of some or all of the foreskin (prepuce) from the penis.[1] The word "circumcision" comes from Latin circum (meaning "around") and cædere (meaning "to cut").
Early depictions of circumcision are found in cave drawings and Ancient Egyptian tombs, though some pictures may be open to interpretation.[2][3][4] Male circumcision is considered a commandment from God in Judaism.[5] In Islam, though not discussed in the Qur'an, circumcision is widely practiced and most often considered to be a sunnah.[6] It is also customary in some Christian churches in Africa, including some Oriental Orthodox Churches.[7] According to the World Health Organization (WHO), global estimates suggest that 30% of males are circumcised, of whom 68% are Muslim.[8] The prevalence of circumcision varies mostly with religious affiliation, and sometimes culture. Most circumcisions are performed during adolescence for cultural or religious reasons.[9]
There is controversy surrounding circumcision. Advocates of circumcision argue, for example, that it provides important health advantages which outweigh the risks, has no substantial effects on sexual function, has a low complication rate when carried out by an experienced physician, and is best performed during the neonatal period.[10] Opponents of circumcision argue, for example, that it is a practice which has historically been, and continues to be, defended through the use of various myths; that it interferes with normal sexual function; is extremely painful; and when performed on infants and children violates the individual's human rights.[11]
The American Medical Association stated in 1999: "Virtually all current policy statements from specialty societies and medical organizations do not recommend routine neonatal circumcision, and support the provision of accurate and unbiased information to parents to inform their choice."[12]
The World Health Organization (WHO; 2007), the Joint United Nations Programme on HIV/AIDS (UNAIDS; 2007), and the Centers for Disease Control and Prevention (CDC; 2008) state that evidence indicates male circumcision significantly reduces the risk of HIV acquisition by men during penile-vaginal sex, but also state that circumcision only provides partial protection and should not replace other interventions to prevent transmission of HIV.[13][14]
Modern circumcision procedures
For infant circumcision, modern devices such as the Gomco clamp, Plastibell, and Mogen clamp are available.[15]
With all modern devices the same basic procedure is followed. First, the amount of foreskin to be removed is estimated. The foreskin is then opened via the preputial orifice to reveal the glans underneath and ensure it is normal. The inner lining of the foreskin (preputial epithelium) is then bluntly separated from its attachment to the glans. The device is then placed (this sometimes requires a dorsal slit) and remains there until blood flow has stopped. Finally, the foreskin is amputated.[16]
* With the Plastibell, adhesions between the glans and inner preputial epithelium having been separated with a probe, the foreskin is cut longitudinally, the Plastibell is placed over the glans and the foreskin is placed over the Plastibell. A ligature is then tied firmly around the foreskin and tightened into a groove in the Plastibell to achieve hemostasis. Foreskin distal to the ligature is excised and the handle is snapped off the Plastibell device. The Plastibell falls from the penis after the wound has healed, typically in four to six days.[17]
* With a Gomco clamp, a section of skin is dorsally crushed with a hemostat and then slit with scissors. The foreskin is drawn over the bell shaped portion of the clamp and inserted through a hole in the base of the clamp. The clamp is tightened, "crushing the foreskin between the bell and the base plate." The crushed blood vessels provide hemostasis. The flared bottom of the bell fits tightly against the hole of the base plate, so the foreskin may be cut away with a scalpel from above the base plate. [18]
* With a Mogen clamp, the foreskin is pulled dorsally with a straight hemostat, and lifted. The Mogen clamp is then slid between the glans and hemostat, following the angle of the corona to "avoid removing excess skin ventrally and to obtain a superior cosmetic result" to Gomco or Plastibell circumcisions. The clamp is locked, and a scalpel is used to cut the skin from the flat (upper) side of the clamp.[19][20]
Adult circumcisions are often performed without clamps and require 4 to 6 weeks of abstinence from masturbation or intercourse after the operation to allow the wound to heal.[21] In some African countries, male circumcision is often performed by non-medical personnel under unsterile conditions.[22] After hospital circumcision, the foreskin may be used in biomedical research,[23] consumer skin-care products,[24] skin grafts,[25][26][27] or β-interferon-based drugs.[28] In parts of Africa, the foreskin may be dipped in brandy and eaten by the patient, eaten by the circumciser, or fed to animals.[29] According to Jewish law, after a Brit milah, the foreskin should be buried.[30]
Cultures and religions
In some cultures, males must be circumcised shortly after birth, during childhood, or around puberty as part of a rite of passage. Circumcision is commonly practised in the Jewish and Islamic faiths.
Jewish law states that circumcision is a 'mitzva aseh ("positive commandment" to perform an act) and is obligatory for Jewish-born males and some Jewish male converts. It is only postponed or abrogated in the case of threat to the life or health of the child.[31] It is usually performed by a mohel on the eighth day after birth in a ceremony called a Brit milah (or Bris milah, colloquially simply bris), which means "Covenant of circumcision" in Hebrew. It is considered of such religious importance that the body of an uncircumcised Jewish male will sometimes be circumcised before burial.[32]
In Islam, circumcision is mentioned in some hadith, but not in the Qur'an. Some Fiqh scholars state that circumcision is recommended (Sunnah); others that it is obligatory.[33] Some have quoted the hadith to argue that the requirement of circumcision is based on the covenant with Abraham.[34] While endorsing circumcision for males, Islamic scholars note that it is not a requirement for converting to Islam.[35]
Illustrated account of the circumcision ceremony of Sultan Ahmed III's three sons.
The Catholic Church condemned the observance of circumcision as a mortal sin and ordered against its practice in the Council of Basel-Florence in 1442.[36]
Circumcision is customary among the Coptic, Ethiopian, and Eritrean Orthodox Churches, and also some other African churches.[7] Some Christian churches in South Africa oppose circumcision, viewing it as a pagan ritual, while others, including the Nomiya church in Kenya,[7][37] require circumcision for membership. Some Christian churches celebrate the Circumcision of Christ.[38][39] The vast majority of Christians do not practise circumcision as a religious requirement.
Circumcision in South Korea is largely the result of American cultural and military influence following the Korean War. In West Africa infant circumcision may have had tribal significance as a rite of passage or otherwise in the past; today in some non-Muslim Nigerian societies it is medicalised and is simply a cultural norm.[40]
Circumcision of Jesus. Illumination from a missal, ca 1460. [41]
Circumcision is part of initiation rites in some African, Pacific Islander, and Australian aboriginal traditions in areas such as Arnhem Land,[42] where the practice was introduced by Makassan traders from Sulawesi in the Indonesian Archipelago.[43] Circumcision ceremonies among certain Australian aboriginal societies are noted for their painful nature: subincision is practised amongst some aboriginal peoples in the Western Desert.[44] In the Pacific, ritual circumcision is nearly universal in the Melanesian islands of Fiji and Vanuatu;[45] participation in the traditional land diving on Pentecost Island is reserved for those who have been circumcised.[46]
Among some West African groups, such as the Dogon and Dowayo, circumcision is taken to represent a removal of "feminine" aspects of the male, turning boys into fully masculine males.[47] Among the Urhobo of southern Nigeria it is symbolic of a boy entering into manhood. The ritual expression, Omo te Oshare ("the boy is now man"), constitutes a rite of passage from one age set to another.[48] For Nilotic peoples, such as the Kalenjin and Maasai, circumcision is a rite of passage observed collectively by a number of boys every few years, and boys circumcised at the same time are taken to be members of a single age set.[49]
Ethical, psychological and legal considerations
Ethical issues
Opponents of circumcision question the ethical validity of removing healthy, functioning genital tissue from a minor, arguing that infant circumcision infringes upon individual autonomy and represents a human rights violation.[50][51][52] Proponents of circumcision argue that circumcision prevents infections and slows down the spread of AIDS.[53]
Consent
Views differ on whether limits should be placed on caregivers having a child circumcised.
Some medical associations take the position that the parents should determine what is in the best interest of the infant or child,[16][54][55] but the Royal Australasian College of Physicians (RACP) and the British Medical Association (BMA) observe that controversy exists on this issue.[56][57] The BMA state that in general, "the parents should determine how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices." They state that because the parents' interests and the child's interests sometimes differ, there are "limits on parents' rights to choose and parents are not entitled to demand medical procedures contrary to their child's best interests." They state that competent children may decide for themselves.[57] UNAIDS states that "[m]ale circumcision is a voluntary surgical procedure and health care providers must ensure that men and young boys are given all the necessary information to enable them to make free and informed choices either for or against getting circumcised."[58]
Some argue that the medical problems that have their risk reduced by circumcision are already rare, can be avoided, and, if they occur, can usually be treated in less invasive ways than circumcision. Somerville states that the removal of healthy genital tissue from a minor should not be subject to parental discretion and that physicians who perform the procedure are not acting in accordance with their ethical duties to the patient.[50] Denniston states that circumcision is harmful and asserts that in the absence of the individual's consent, non-therapeutic child circumcision violates several ethical principles that govern medicine.[59]
Others believe neonatal circumcision is permissible, if parents should so choose. Viens argues that, in a cultural or religious context, circumcision is of significant enough importance that parental consent is sufficient and that there is "an absence of sufficient evidence or persuasive argumentation" to support changing the present policy.[60] Benatar and Benatar argue that circumcision can be beneficial to a male before he would be able to otherwise provide consent, that "it is far from obvious that circumcision reduces sexual pleasure," and that "it is far from clear that non-circumcision leaves open a future person’s options in every regard."[61]
Acknowledgment of pain
Williams (2003) argued that human attitudes toward the pain that animals (including humans) experience may not be based on speciesism; developing an analogy between attitudes toward the pain pigs endure while having their tails "docked", and "our culture's indifference to the pain that male human infants experience while being circumcised."[62]
Psychological and emotional consequences
The British Medical Association (2006) states that "it is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks."[57] Goldman (1999) discussed the possible trauma of circumcision on children and parents, anxieties over the circumcised state, a tendency to repeat the trauma, and suggested a need on the part of circumcised doctors to find medical justifications for the procedure.[63] Milos and Macris (1992) argue that circumcision encodes the perinatal brain with violence and negatively affects infant-maternal bonding and trust.[11] Moses et al. (1998) state that "scientific evidence is lacking" for psychological and emotional harm, and cite a longitudinal study which did not find a difference in developmental and behavioural indices.[64] In the United States, the Centers for Disease Control and Prevention stated: "In a study of adolescents, only 69% of circumcised and 65% of uncircumcised young men correctly identified their circumcision status as verified by physical exam."[65]
Legal issues
In 2001, Sweden passed a law allowing only persons certified by the National Board of Health to circumcise infants, requiring a medical doctor or an anesthesia nurse to accompany the circumciser and for anaesthetic to be applied beforehand. Jews and Muslims in Sweden objected to the law,[66] and in 2001, the World Jewish Congress stated that it was “the first legal restriction on Jewish religious practice in Europe since the Nazi era.”[67] In 2005, the Swedish National Board of Health and Welfare reviewed the law and recommended that it be maintained. In 2006, the U.S. State Department's report on Sweden stated that most Jewish mohels had been certified under the law and 3000 Muslim and 40–50 Jewish boys were circumcised each year.[68]
In 2006, a Finnish court found that a parent's actions in having her 4-year-old son circumcised was illegal.[69] However, no punishment was assigned by the court, and in 2008 the Finnish Supreme Court ruled that the mother's actions did not constitute a criminal offense and that circumcision of a child for religious reasons, when performed properly, is not a crime.[70] In 2008, the Finnish government was reported to be considering a new law to legalize ritual circumcision if the practitioner is a doctor, "according to the parents' wishes, and with the child's consent", as reported.[71]
A San Diego, California-based group submitted a proposed bill to U.S. Congress called the Male Genital Mutilation Bill ("MGM bill"), seeking to ban the practice of circumcising baby boys. In 2005, a CNN columnist stated that the bill had not yet found a Congressional sponsor, but that it raised "important questions about the relationship between the protection of children, gender equality, and religious freedom, questions that have ramifications beyond the proposed bill itself."[72]
In March 2009 a jury awarded $2.3 million in damages to a 4-year-old boy and his mother for a botched circumcision.[73]
Medical aspects
Medical cost-benefit analyses of circumcision have varied. Some found a small net benefit of circumcision,[74][75] some found a small net decrement,[76][77] and one found that the benefits and risks balanced each other out and suggested that the decision could "most reasonably be made on nonmedical factors."[78]
Pain and pain relief during circumcision
According to the American Academy of Pediatrics' 1999 Circumcision Policy Statement, “There is considerable evidence that newborns who are circumcised without analgesia experience pain and psychologic stress.”[16] It therefore recommended using pain relief for circumcision.[16] One of the supporting studies, Taddio 1997, found a correlation between circumcision and intensity of pain response during vaccination months later.[79] While acknowledging that there may be "other factors" besides circumcision to account for different levels of pain response, they stated that they did not find evidence of such. They concluded "pretreatment and postoperative management of neonatal circumcision pain is recommended based on these results."[79] Other medical associations also cite evidence that circumcision without anesthetic is painful.[80][81]
Stang, 1998, found 45% of physicians responding to a survey who circumcise used anaesthesia – most commonly a dorsal penile nerve block – for infant circumcisions. The obstetricians in the sample used anaesthesia less often (25%) than the family practitioners (56%) or pediatricians (71%).[82] Howard et al. (1998) surveyed US medical doctor residency programs and directors, and found that 26% of the programs that taught the circumcision procedure "failed to provide instruction in anesthesia/analgesia for the procedure."[83] A 2006 follow-up study revealed that the percentage of programs that taught circumcision and also taught administration of topical or local anesthetic had increased to 97%.[84] However, the authors of the follow-up study also noted that only 84% of these programs used anesthetic "frequently or always" when the procedure was conducted.[84]
J.M. Glass, 1999, stated that Jewish ritual circumcision is so quick that "most mohelim do not routinely use any anaesthesia as they feel there is probably no need in the neonate. However, there is no Talmudic objection and should the parents wish for local anaesthetic cream to be applied there is no reason why this cannot be done."[31] Other researchers claim that because traditional Jewish bris is rapid and does not rely on clamps or ligature for hemostasis, it is less painful than other circumcision techniques, and that the pain of an analgesic injection would actually cause more distress than the procedure itself.[85]
Lander et al. demonstrated that babies circumcised without anesthesia showed behavioral and physiological signs of pain and distress.[86] Comparisons of the dorsal penile nerve block and EMLA (lidocaine/prilocaine) topical cream methods of pain control have revealed that while both are safe,[87][88] the dorsal nerve block controls pain more effectively than topical treatments,[89] but neither method eliminates pain completely.[87] Razmus et al. reported that newborns circumcised with the dorsal block and the ring block in combination with the concentrated oral sucrose had the lowest pain scores.[90] Ng et al. found that EMLA cream, in addition to local anaesthetic, effectively reduces the sharp pain induced by needle puncture.[91]
Complications
One study looking at 354,297 births in Washington State from 1987-1996 found that immediate post-birth complications occurred at a rate of 0.2% in the circumcised babies and at a rate of 0.01% in the uncircumcised babies. The authors judged that this was a conservative estimate because it did not capture the very rare but serious delayed complications associated with circumcisions (eg, necrotizing fasciitis, cellulitis) and the less serious but more common complications such as the circumcision scar or a less than ideal cosmetic result. They also stated that the risks of circumcision "do not seem to be mitigated by the hands of more experienced physicians".[107]
Meatal stenosis (a narrowing of the urethral opening) may be a longer-term complication of circumcision. It is thought that because the foreskin no longer protects the meatus, ammonia formed from urine in wet diapers irritates and inflames the exposed urethral opening. Meatal stenosis can lead to discomfort with urination, incontinence, bleeding after urination and urinary tract infections.[108][109][110]
Circumcisions may remove too much or too little skin.[111][104] If insufficient skin is removed, the child may still develop phimosis in later life.[104] Van Howe states that "when operating on the infantile penis, the surgeon cannot adequately judge the appropriate amount of tissue to remove because the penis will change considerably as the child ages, such that a small difference at the time of surgery may translate into a large difference in the adult circumcised penis. To date (1997), there have been no published studies showing the ability of a circumciser to predict the later appearance of the penis."[112]
Cathcart et al. report that 0.5% of boys required a procedure to revise the circumcision.[113]
Other complications include concealed penis[114][115], urinary fistulas, chordee, cysts, lymphedema, ulceration of the glans, necrosis of all or part of the penis, hypospadias, epispadias and impotence.[105] Kaplan stated “Virtually all of these complications are preventable with only a modicum of care" and "most such complications occur at the hands of inexperienced operators who are neither urologists nor surgeons.”[105]
An uncommon complication of infant circumcision is skin bridge formation, whereby the end of the severed part of the foreskin fuses to other parts of the penis (normally the glans) on repair. This can result in pain during erections and sometimes minor bleeding can occur if the shaft skin is forcibly retracted.[116] Van Howe advises that to prevent adhesions forming after circumcision, parents should be instructed to retract and clean any skin covering the glans.[112]
Although deaths have been reported,[105][117] the American Academy of Family Physicians states that death is rare, and cites an estimated death rate of 1 infant in 500,000 from circumcision.[80] Gairdner's 1949 study[118] reported that an average of 16 children per year out of about 90,000 died following circumcision in the UK. He found that most deaths had occurred suddenly under anaesthesia and could not be explained further, but hemorrhage and infection had also proven fatal. Deaths attributed to phimosis and circumcision were grouped together, but Gairdner argued that such deaths were probably due to the circumcision operation. The penis is thought to be lost in 1 in 1,000,000 circumcisions.[119]
Hygiene, and infectious and chronic conditions
The American Academy of Pediatrics (1999) stated: "Circumcision has been suggested as an effective method of maintaining penile hygiene since the time of the Egyptian dynasties, but there is little evidence to affirm the association between circumcision status and optimal penile hygiene."[16]
An inflammation of the glans penis and foreskin is called balanoposthitis; that affecting the glans alone is called balanitis. Both conditions are usually treated with topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams. Although not as necessary as in the past, circumcision may be considered for recurrent or resistant cases.[144][145] Escala and Rickwood recommend against a policy of routine infant circumcision to avoid balanitis saying that the condition affects no more than 4% of boys, does not cause pathological phimosis, and in most cases is not serious.[146]
Fergusson studied 500 boys and found that by 8 years, the circumcised children had a rate of 11.1 problems per 100 children, and the uncircumcised children had a rate of 18.8 per 100. During infancy, circumcised children were found to have a significantly higher risk of problems than uncircumcised children, but after infancy the rate of penile problems was significantly higher among the uncircumcised. Fergusson et al. said that the great majority of penile problems were relatively minor (penile inflammation including balanitis, meatitis, and inflammation of the prepuce) and most (64%) were resolved after a single medical consultation.[147] Herzog and Alverez found the overall frequency of complications (including balanitis, irritation, adhesions, phimosis, and paraphimosis) to be higher among the uncircumcised children; again, most of the problems were minor.[148] In a study of 398 randomly selected dermatology students, Fakjian et al. reported: "Balanitis was diagnosed in 2.3% of circumcised men and in 12.5% of uncircumcised men."[149] In a study of 225 men, O'Farrell et al. reported: "Overall, circumcised men were less likely to be diagnosed with a STI/balanitis (51% and 35%, P = 0.021) than those non-circumcised."[150] Van Howe found that circumcised penes required more care in the first 3 months of life, and that circumcised boys are more likely to develop balanitis.[151]
The American Medical Association state that circumcision, properly performed, protects against the development of phimosis.[54] Rickwood and other authors have argued that many infant circumcisions are performed unnecessarily for developmental non-retractability of the prepuce rather than for pathological phimosis.[152][153] Metcalfe et al. stated that "Gairdner[118] and Oster[154] made a strong case for leaving boys uncircumcised, allowing the natural separation of the foreskin from the glans to take place gradually, and instructing boys in proper hygiene. This obviates the need for 'preventive' circumcision."[155] In a study to determine the most cost-effective treatment for phimosis, Van Howe concluded that using cream was 75% more cost-effective than circumcision at treating pathological phimosis.[156]
Urinary tract infections
A meta-analysis of 12 studies (one randomised controlled trial, four cohort studies and seven case-control studies) representing 402,908 children determined that circumcision was associated with a significantly reduced risk of urinary tract infection (UTI). However, the authors noted that only 1% of boys with normal urinary tract function experience a UTI, and the number-needed-to treat (number of circumcisions necessary) to prevent one urinary tract infection was calculated to be 111. Because haemorrhage and infection are the commonest complications of circumcision, occurring at rate of about 2%, assuming equal utility of benefits and harms, the authors concluded that the net clinical benefit of circumcision is only likely in boys at high risk of urinary tract infection (such as those with high grade vesicoureteral reflux or a history of recurrent UTIs, where the number needed to treat declined to 11 and 4, respectively).[157]
Some UTI studies have been criticized for not taking into account a high rate of UTI's among premature infants, who are usually not circumcised because of their fragile health status.[16] The AMA stated that “depending on the model employed, approximately 100 to 200 circumcisions would need to be performed to prevent 1 UTI," and noted one decision analysis model that concluded that circumcision was not justified as a preventative measure against UTI.[54]
Policies of various national medical associations
Most guidelines make a distinction between therapeutic and non-therapeutic circumcision. Therapeutic circumcision (where there is a medical need to circumcise) is rarely controversial. Neonatal circumcision is not considered medically necessary and is therefore categorised as non-therapeutic.[citation needed]
Australasia
The Royal Australasian College of Physicians (RACP) state that "after extensive review of the literature" they "reaffirm that there is no medical indication for routine neonatal circumcision". They also state that "if the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment." Additionally, the RACP state that there is an obligation to provide parents who request a circumcision for their child with accurate, up-to-date and unbiased information about the risks and benefits of circumcision, adding that "there is no evidence of benefit outweighing harm for circumcision as a routine procedure in the neonate."[56]
The Tasmanian President of the Australian Medical Association (AMA), Haydn Walters, has stated that the AMA would support a call to ban circumcision for non-medical, non-religious reasons.[161]
Canada
The Fetus and Newborn Committee of the Canadian Paediatric Society posted "Neonatal circumcision revisited" in 1996 and "Circumcision: Information for Parents" in November 2004.[81] The 1996 position statement says that "circumcision of newborns should not be routinely performed," (a statement with which the Royal Australasian College of Physicians concurs), and the 2004 advice to parents says it "does not recommend circumcision for newborn boys. Many pediatricians no longer perform circumcisions."[55]
United Kingdom
There is a spectrum of views within the British Medical Association's (BMA) membership about whether non-therapeutic male circumcision is a beneficial, neutral or harmful procedure or whether it is superfluous, and whether it should ever be done on a child who is not capable of deciding for himself. Moreover, the Association states that “there is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure. At present, the medical literature on the health, including sexual health, implications of circumcision is contradictory, and often subject to claims of bias in research.”[57] As a general rule, the BMA believe that "parents should be entitled to make choices about how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices." They also state that "both parents...must give consent for non-therapeutic circumcision", and that parents and children should be provided with up-to-date written information about the risks involved.[57]
According to the BMA, circumcision for medical purposes should only be used where less invasive procedures are either unavailable or not as effective. They state that "to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate." Furthermore, the BMA believe that children who are capable of expressing a view should be involved in the decision-making process with regard to their own circumcision, and their views should be taken into account. The BMA state that they "cannot envisage a situation in which it is ethically acceptable to circumcise a competent, informed young person who consistently refuses the procedure."[57]
The BMA state that parents should be informed about the lack of consensus within the medical profession with regard to the potential health benefits of non-therapeutic circumcision, adding that they consider the evidence for such benefits to be insufficient as the sole reason for carrying out a circumcision.[57]
United States
The American Academy of Pediatrics (1999) stated: "Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision, in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child."[16] The AAP recommends that if parents choose to circumcise, analgesia should be used to reduce pain associated with circumcision. It states that circumcision should only be performed on newborns who are stable and healthy.[16]
The American Medical Association supports the AAP's 1999 circumcision policy statement with regard to non-therapeutic circumcision, which they define as the non-religious, non-ritualistic, not medically necessary, elective circumcision of male newborns. They state that "policy statements issued by professional societies representing Australian, Canadian, and American pediatricians do not recommend routine circumcision of male newborns."[54]
The American Academy of Family Physicians (2007) recognizes the controversy surrounding circumcision and recommends that physicians "discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn son."[162]
The American Urological Association (2007) stated that neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks.[163]
History of circumcision
It has been variously proposed that circumcision began as a religious sacrifice, as a rite of passage marking a boy's entrance into adulthood, as a form of sympathetic magic to ensure virility, as a means of suppressing sexual pleasure or to increase a man's attractiveness to women, or as an aid to hygiene where regular bathing was impractical, among other possibilities. Immerman et al. suggest that circumcision causes lowered sexual arousal of pubescent males, and hypothesize that this was a competitive advantage to tribes practicing circumcision, leading to its spread regardless of whether the people understood this.[164] It is possible that circumcision arose independently in different cultures for different reasons.
Family circumcision set and trunk, ca. eighteenth century Wooden box covered in cow hide with silver implements: silver trays, clip, pointer, silver flask, spice vessel.
The oldest documentary evidence for circumcision comes from ancient Egypt.[165] Circumcision was common, although not universal, among ancient Semitic peoples.[166] In the aftermath of the conquests of Alexander the Great, however, Greek dislike of circumcision (they regarded a man as truly "naked" only if his prepuce was retracted) led to a decline in its incidence among many peoples that had previously practiced it.[167]
Circumcision has ancient roots among several ethnic groups in sub-equatorial Africa, and is still performed on adolescent boys to symbolize their transition to warrior status or adulthood.[168]
Circumcision in the English-speaking world
Infant circumcision was taken up in the United States, Australia and the English-speaking parts of Canada, South Africa, New Zealand and to a lesser extent in the United Kingdom. There are several hypotheses to explain why infant circumcision was accepted in the United States about the year 1900. The germ theory of disease elicited an image of the human body as a conveyance for many dangerous germs, making the public "germ phobic" and suspicious of dirt and bodily secretions. The penis became "dirty" by association with its function, and from this premise circumcision was seen as preventative medicine to be practiced universally.[169] In the view of many practitioners at the time, circumcision was a method of treating and preventing masturbation.[169] Aggleton wrote that John Kellogg viewed male circumcision in this way, and further "advocated an unashamedly punitive approach."[170] Circumcision was also said to protect against syphilis,[171] phimosis, paraphimosis, balanitis, and "excessive venery" (which was believed to produce paralysis).[169] Gollaher states that physicians advocating circumcision in the late nineteenth century expected public skepticism, and refined their arguments to overcome it.[169]
Although it is difficult to determine historical circumcision rates, one estimate of infant circumcision rates in the United States holds that 32% of newborn American boys were being circumcised in 1933.[98] Laumann et al. reported that the prevalence of circumcision among US-born males was approximately 70%, 80%, 85%, and 77% for those born in 1945, 1955, 1965, and 1971 respectively.[98] Xu et al. reported that the prevalence of circumcision among US-born males was 91% for males born in the 1970s and 84% for those born in the 1980s.[172] Between 1981 and 1999, National Hospital Discharge Survey data from the National Center for Health Statistics demonstrated that the infant circumcision rate remained relatively stable within the 60% range, with a minimum of 60.7% in 1988 and a maximum of 67.8% in 1995.[173] A 1987 study found that the most prominent reasons US parents choose circumcision were "concerns about the attitudes of peers and their sons' self concept in the future," rather than medical concerns.[174] However, a later study speculated that an increased recognition of the potential benefits of neonatal circumcision may have been responsible for the observed increase in the US rate between 1988 and 2000.[175] A report by the Agency for Healthcare Research and Quality placed the 2005 national circumcision rate at 56%.[176]
In 1949, the United Kingdom's newly-formed National Health Service removed infant circumcision from its list of covered services, and circumcision has since been an out-of-pocket cost to parents. As a result, prevalence in the UK is age-graded, with 12% of those aged 16-19 years circumcised and 20% of those aged 40-44 years,[177] and the proportion of newborns circumcised in England and Wales has fallen to less than one percent.
The circumcision rate has declined sharply in Australia since the 1970s, leading to an age-graded fall in prevalence, with a 2000-01 survey finding 32% of those aged 16-19 years circumcised, 50% for 20-29 years and 64% for those aged 30-39 years.[178][179]
In Canada, individual provincial health services began delisting circumcision in the 1980s.[citation needed]
Prevalence of circumcision
Estimates of the proportion of males that are circumcised worldwide vary from one-sixth[104] to a third.[180] The WHO has estimated that 664,500,000 males aged 15 and over are circumcised (30% global prevalence), with almost 70% of these being Muslim.[8] Circumcision is most prevalent in the Muslim world, parts of South East Asia, Africa, the United States, The Philippines, Israel, and South Korea. It is relatively rare in Europe, Latin America, parts of Southern Africa, and most of Asia and Oceania. Prevalence is near-universal in the Middle East and Central Asia.[8] The WHO states that "there is generally little non-religious circumcision in Asia, with the exceptions of the Republic of Korea and the Philippines".[8] The WHO presents a map of estimated prevalence in which the level is generally low (< 20%) across Europe,[8] and Klavs et al. report findings that "support the notion that the prevalence is low in Europe".[181] In Latin America, prevalence is universally low.[182] Estimates for individual countries include Spain[183], Colombia[183] and Denmark[184] less than 2%, Finland[185] and Brazil[183] 7%, Taiwan[186] 9%, Thailand[183] 13%, New Zealand[187] less than 20% and Australia[179] 58.7%.
The WHO estimates prevalence in the United States and Canada at 75% and 30%, respectively.[8] Prevalence in Africa varies from less than 20% in some southern African countries to near universal in North and West Africa.
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Circumcision
Male circumcision is the removal of some or all of the foreskin (prepuce) from the penis.[1] The word "circumcision" comes from Latin circum (meaning "around") and cædere (meaning "to cut").
Early depictions of circumcision are found in cave drawings and Ancient Egyptian tombs, though some pictures may be open to interpretation.[2][3][4] Male circumcision is considered a commandment from God in Judaism.[5] In Islam, though not discussed in the Qur'an, circumcision is widely practiced and most often considered to be a sunnah.[6] It is also customary in some Christian churches in Africa, including some Oriental Orthodox Churches.[7] According to the World Health Organization (WHO), global estimates suggest that 30% of males are circumcised, of whom 68% are Muslim.[8] The prevalence of circumcision varies mostly with religious affiliation, and sometimes culture. Most circumcisions are performed during adolescence for cultural or religious reasons.[9]
There is controversy surrounding circumcision. Advocates of circumcision argue, for example, that it provides important health advantages which outweigh the risks, has no substantial effects on sexual function, has a low complication rate when carried out by an experienced physician, and is best performed during the neonatal period.[10] Opponents of circumcision argue, for example, that it is a practice which has historically been, and continues to be, defended through the use of various myths; that it interferes with normal sexual function; is extremely painful; and when performed on infants and children violates the individual's human rights.[11]
The American Medical Association stated in 1999: "Virtually all current policy statements from specialty societies and medical organizations do not recommend routine neonatal circumcision, and support the provision of accurate and unbiased information to parents to inform their choice."[12]
The World Health Organization (WHO; 2007), the Joint United Nations Programme on HIV/AIDS (UNAIDS; 2007), and the Centers for Disease Control and Prevention (CDC; 2008) state that evidence indicates male circumcision significantly reduces the risk of HIV acquisition by men during penile-vaginal sex, but also state that circumcision only provides partial protection and should not replace other interventions to prevent transmission of HIV.[13][14]
Modern circumcision procedures
For infant circumcision, modern devices such as the Gomco clamp, Plastibell, and Mogen clamp are available.[15]
With all modern devices the same basic procedure is followed. First, the amount of foreskin to be removed is estimated. The foreskin is then opened via the preputial orifice to reveal the glans underneath and ensure it is normal. The inner lining of the foreskin (preputial epithelium) is then bluntly separated from its attachment to the glans. The device is then placed (this sometimes requires a dorsal slit) and remains there until blood flow has stopped. Finally, the foreskin is amputated.[16]
* With the Plastibell, adhesions between the glans and inner preputial epithelium having been separated with a probe, the foreskin is cut longitudinally, the Plastibell is placed over the glans and the foreskin is placed over the Plastibell. A ligature is then tied firmly around the foreskin and tightened into a groove in the Plastibell to achieve hemostasis. Foreskin distal to the ligature is excised and the handle is snapped off the Plastibell device. The Plastibell falls from the penis after the wound has healed, typically in four to six days.[17]
* With a Gomco clamp, a section of skin is dorsally crushed with a hemostat and then slit with scissors. The foreskin is drawn over the bell shaped portion of the clamp and inserted through a hole in the base of the clamp. The clamp is tightened, "crushing the foreskin between the bell and the base plate." The crushed blood vessels provide hemostasis. The flared bottom of the bell fits tightly against the hole of the base plate, so the foreskin may be cut away with a scalpel from above the base plate. [18]
* With a Mogen clamp, the foreskin is pulled dorsally with a straight hemostat, and lifted. The Mogen clamp is then slid between the glans and hemostat, following the angle of the corona to "avoid removing excess skin ventrally and to obtain a superior cosmetic result" to Gomco or Plastibell circumcisions. The clamp is locked, and a scalpel is used to cut the skin from the flat (upper) side of the clamp.[19][20]
Adult circumcisions are often performed without clamps and require 4 to 6 weeks of abstinence from masturbation or intercourse after the operation to allow the wound to heal.[21] In some African countries, male circumcision is often performed by non-medical personnel under unsterile conditions.[22] After hospital circumcision, the foreskin may be used in biomedical research,[23] consumer skin-care products,[24] skin grafts,[25][26][27] or β-interferon-based drugs.[28] In parts of Africa, the foreskin may be dipped in brandy and eaten by the patient, eaten by the circumciser, or fed to animals.[29] According to Jewish law, after a Brit milah, the foreskin should be buried.[30]
Cultures and religions
In some cultures, males must be circumcised shortly after birth, during childhood, or around puberty as part of a rite of passage. Circumcision is commonly practised in the Jewish and Islamic faiths.
Jewish law states that circumcision is a 'mitzva aseh ("positive commandment" to perform an act) and is obligatory for Jewish-born males and some Jewish male converts. It is only postponed or abrogated in the case of threat to the life or health of the child.[31] It is usually performed by a mohel on the eighth day after birth in a ceremony called a Brit milah (or Bris milah, colloquially simply bris), which means "Covenant of circumcision" in Hebrew. It is considered of such religious importance that the body of an uncircumcised Jewish male will sometimes be circumcised before burial.[32]
In Islam, circumcision is mentioned in some hadith, but not in the Qur'an. Some Fiqh scholars state that circumcision is recommended (Sunnah); others that it is obligatory.[33] Some have quoted the hadith to argue that the requirement of circumcision is based on the covenant with Abraham.[34] While endorsing circumcision for males, Islamic scholars note that it is not a requirement for converting to Islam.[35]
Illustrated account of the circumcision ceremony of Sultan Ahmed III's three sons.
The Catholic Church condemned the observance of circumcision as a mortal sin and ordered against its practice in the Council of Basel-Florence in 1442.[36]
Circumcision is customary among the Coptic, Ethiopian, and Eritrean Orthodox Churches, and also some other African churches.[7] Some Christian churches in South Africa oppose circumcision, viewing it as a pagan ritual, while others, including the Nomiya church in Kenya,[7][37] require circumcision for membership. Some Christian churches celebrate the Circumcision of Christ.[38][39] The vast majority of Christians do not practise circumcision as a religious requirement.
Circumcision in South Korea is largely the result of American cultural and military influence following the Korean War. In West Africa infant circumcision may have had tribal significance as a rite of passage or otherwise in the past; today in some non-Muslim Nigerian societies it is medicalised and is simply a cultural norm.[40]
Circumcision of Jesus. Illumination from a missal, ca 1460. [41]
Circumcision is part of initiation rites in some African, Pacific Islander, and Australian aboriginal traditions in areas such as Arnhem Land,[42] where the practice was introduced by Makassan traders from Sulawesi in the Indonesian Archipelago.[43] Circumcision ceremonies among certain Australian aboriginal societies are noted for their painful nature: subincision is practised amongst some aboriginal peoples in the Western Desert.[44] In the Pacific, ritual circumcision is nearly universal in the Melanesian islands of Fiji and Vanuatu;[45] participation in the traditional land diving on Pentecost Island is reserved for those who have been circumcised.[46]
Among some West African groups, such as the Dogon and Dowayo, circumcision is taken to represent a removal of "feminine" aspects of the male, turning boys into fully masculine males.[47] Among the Urhobo of southern Nigeria it is symbolic of a boy entering into manhood. The ritual expression, Omo te Oshare ("the boy is now man"), constitutes a rite of passage from one age set to another.[48] For Nilotic peoples, such as the Kalenjin and Maasai, circumcision is a rite of passage observed collectively by a number of boys every few years, and boys circumcised at the same time are taken to be members of a single age set.[49]
Ethical, psychological and legal considerations
Ethical issues
Opponents of circumcision question the ethical validity of removing healthy, functioning genital tissue from a minor, arguing that infant circumcision infringes upon individual autonomy and represents a human rights violation.[50][51][52] Proponents of circumcision argue that circumcision prevents infections and slows down the spread of AIDS.[53]
Consent
Views differ on whether limits should be placed on caregivers having a child circumcised.
Some medical associations take the position that the parents should determine what is in the best interest of the infant or child,[16][54][55] but the Royal Australasian College of Physicians (RACP) and the British Medical Association (BMA) observe that controversy exists on this issue.[56][57] The BMA state that in general, "the parents should determine how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices." They state that because the parents' interests and the child's interests sometimes differ, there are "limits on parents' rights to choose and parents are not entitled to demand medical procedures contrary to their child's best interests." They state that competent children may decide for themselves.[57] UNAIDS states that "[m]ale circumcision is a voluntary surgical procedure and health care providers must ensure that men and young boys are given all the necessary information to enable them to make free and informed choices either for or against getting circumcised."[58]
Some argue that the medical problems that have their risk reduced by circumcision are already rare, can be avoided, and, if they occur, can usually be treated in less invasive ways than circumcision. Somerville states that the removal of healthy genital tissue from a minor should not be subject to parental discretion and that physicians who perform the procedure are not acting in accordance with their ethical duties to the patient.[50] Denniston states that circumcision is harmful and asserts that in the absence of the individual's consent, non-therapeutic child circumcision violates several ethical principles that govern medicine.[59]
Others believe neonatal circumcision is permissible, if parents should so choose. Viens argues that, in a cultural or religious context, circumcision is of significant enough importance that parental consent is sufficient and that there is "an absence of sufficient evidence or persuasive argumentation" to support changing the present policy.[60] Benatar and Benatar argue that circumcision can be beneficial to a male before he would be able to otherwise provide consent, that "it is far from obvious that circumcision reduces sexual pleasure," and that "it is far from clear that non-circumcision leaves open a future person’s options in every regard."[61]
Acknowledgment of pain
Williams (2003) argued that human attitudes toward the pain that animals (including humans) experience may not be based on speciesism; developing an analogy between attitudes toward the pain pigs endure while having their tails "docked", and "our culture's indifference to the pain that male human infants experience while being circumcised."[62]
Psychological and emotional consequences
The British Medical Association (2006) states that "it is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks."[57] Goldman (1999) discussed the possible trauma of circumcision on children and parents, anxieties over the circumcised state, a tendency to repeat the trauma, and suggested a need on the part of circumcised doctors to find medical justifications for the procedure.[63] Milos and Macris (1992) argue that circumcision encodes the perinatal brain with violence and negatively affects infant-maternal bonding and trust.[11] Moses et al. (1998) state that "scientific evidence is lacking" for psychological and emotional harm, and cite a longitudinal study which did not find a difference in developmental and behavioural indices.[64] In the United States, the Centers for Disease Control and Prevention stated: "In a study of adolescents, only 69% of circumcised and 65% of uncircumcised young men correctly identified their circumcision status as verified by physical exam."[65]
Legal issues
In 2001, Sweden passed a law allowing only persons certified by the National Board of Health to circumcise infants, requiring a medical doctor or an anesthesia nurse to accompany the circumciser and for anaesthetic to be applied beforehand. Jews and Muslims in Sweden objected to the law,[66] and in 2001, the World Jewish Congress stated that it was “the first legal restriction on Jewish religious practice in Europe since the Nazi era.”[67] In 2005, the Swedish National Board of Health and Welfare reviewed the law and recommended that it be maintained. In 2006, the U.S. State Department's report on Sweden stated that most Jewish mohels had been certified under the law and 3000 Muslim and 40–50 Jewish boys were circumcised each year.[68]
In 2006, a Finnish court found that a parent's actions in having her 4-year-old son circumcised was illegal.[69] However, no punishment was assigned by the court, and in 2008 the Finnish Supreme Court ruled that the mother's actions did not constitute a criminal offense and that circumcision of a child for religious reasons, when performed properly, is not a crime.[70] In 2008, the Finnish government was reported to be considering a new law to legalize ritual circumcision if the practitioner is a doctor, "according to the parents' wishes, and with the child's consent", as reported.[71]
A San Diego, California-based group submitted a proposed bill to U.S. Congress called the Male Genital Mutilation Bill ("MGM bill"), seeking to ban the practice of circumcising baby boys. In 2005, a CNN columnist stated that the bill had not yet found a Congressional sponsor, but that it raised "important questions about the relationship between the protection of children, gender equality, and religious freedom, questions that have ramifications beyond the proposed bill itself."[72]
In March 2009 a jury awarded $2.3 million in damages to a 4-year-old boy and his mother for a botched circumcision.[73]
Medical aspects
Medical cost-benefit analyses of circumcision have varied. Some found a small net benefit of circumcision,[74][75] some found a small net decrement,[76][77] and one found that the benefits and risks balanced each other out and suggested that the decision could "most reasonably be made on nonmedical factors."[78]
Pain and pain relief during circumcision
According to the American Academy of Pediatrics' 1999 Circumcision Policy Statement, “There is considerable evidence that newborns who are circumcised without analgesia experience pain and psychologic stress.”[16] It therefore recommended using pain relief for circumcision.[16] One of the supporting studies, Taddio 1997, found a correlation between circumcision and intensity of pain response during vaccination months later.[79] While acknowledging that there may be "other factors" besides circumcision to account for different levels of pain response, they stated that they did not find evidence of such. They concluded "pretreatment and postoperative management of neonatal circumcision pain is recommended based on these results."[79] Other medical associations also cite evidence that circumcision without anesthetic is painful.[80][81]
Stang, 1998, found 45% of physicians responding to a survey who circumcise used anaesthesia – most commonly a dorsal penile nerve block – for infant circumcisions. The obstetricians in the sample used anaesthesia less often (25%) than the family practitioners (56%) or pediatricians (71%).[82] Howard et al. (1998) surveyed US medical doctor residency programs and directors, and found that 26% of the programs that taught the circumcision procedure "failed to provide instruction in anesthesia/analgesia for the procedure."[83] A 2006 follow-up study revealed that the percentage of programs that taught circumcision and also taught administration of topical or local anesthetic had increased to 97%.[84] However, the authors of the follow-up study also noted that only 84% of these programs used anesthetic "frequently or always" when the procedure was conducted.[84]
J.M. Glass, 1999, stated that Jewish ritual circumcision is so quick that "most mohelim do not routinely use any anaesthesia as they feel there is probably no need in the neonate. However, there is no Talmudic objection and should the parents wish for local anaesthetic cream to be applied there is no reason why this cannot be done."[31] Other researchers claim that because traditional Jewish bris is rapid and does not rely on clamps or ligature for hemostasis, it is less painful than other circumcision techniques, and that the pain of an analgesic injection would actually cause more distress than the procedure itself.[85]
Lander et al. demonstrated that babies circumcised without anesthesia showed behavioral and physiological signs of pain and distress.[86] Comparisons of the dorsal penile nerve block and EMLA (lidocaine/prilocaine) topical cream methods of pain control have revealed that while both are safe,[87][88] the dorsal nerve block controls pain more effectively than topical treatments,[89] but neither method eliminates pain completely.[87] Razmus et al. reported that newborns circumcised with the dorsal block and the ring block in combination with the concentrated oral sucrose had the lowest pain scores.[90] Ng et al. found that EMLA cream, in addition to local anaesthetic, effectively reduces the sharp pain induced by needle puncture.[91]
Complications
One study looking at 354,297 births in Washington State from 1987-1996 found that immediate post-birth complications occurred at a rate of 0.2% in the circumcised babies and at a rate of 0.01% in the uncircumcised babies. The authors judged that this was a conservative estimate because it did not capture the very rare but serious delayed complications associated with circumcisions (eg, necrotizing fasciitis, cellulitis) and the less serious but more common complications such as the circumcision scar or a less than ideal cosmetic result. They also stated that the risks of circumcision "do not seem to be mitigated by the hands of more experienced physicians".[107]
Meatal stenosis (a narrowing of the urethral opening) may be a longer-term complication of circumcision. It is thought that because the foreskin no longer protects the meatus, ammonia formed from urine in wet diapers irritates and inflames the exposed urethral opening. Meatal stenosis can lead to discomfort with urination, incontinence, bleeding after urination and urinary tract infections.[108][109][110]
Circumcisions may remove too much or too little skin.[111][104] If insufficient skin is removed, the child may still develop phimosis in later life.[104] Van Howe states that "when operating on the infantile penis, the surgeon cannot adequately judge the appropriate amount of tissue to remove because the penis will change considerably as the child ages, such that a small difference at the time of surgery may translate into a large difference in the adult circumcised penis. To date (1997), there have been no published studies showing the ability of a circumciser to predict the later appearance of the penis."[112]
Cathcart et al. report that 0.5% of boys required a procedure to revise the circumcision.[113]
Other complications include concealed penis[114][115], urinary fistulas, chordee, cysts, lymphedema, ulceration of the glans, necrosis of all or part of the penis, hypospadias, epispadias and impotence.[105] Kaplan stated “Virtually all of these complications are preventable with only a modicum of care" and "most such complications occur at the hands of inexperienced operators who are neither urologists nor surgeons.”[105]
An uncommon complication of infant circumcision is skin bridge formation, whereby the end of the severed part of the foreskin fuses to other parts of the penis (normally the glans) on repair. This can result in pain during erections and sometimes minor bleeding can occur if the shaft skin is forcibly retracted.[116] Van Howe advises that to prevent adhesions forming after circumcision, parents should be instructed to retract and clean any skin covering the glans.[112]
Although deaths have been reported,[105][117] the American Academy of Family Physicians states that death is rare, and cites an estimated death rate of 1 infant in 500,000 from circumcision.[80] Gairdner's 1949 study[118] reported that an average of 16 children per year out of about 90,000 died following circumcision in the UK. He found that most deaths had occurred suddenly under anaesthesia and could not be explained further, but hemorrhage and infection had also proven fatal. Deaths attributed to phimosis and circumcision were grouped together, but Gairdner argued that such deaths were probably due to the circumcision operation. The penis is thought to be lost in 1 in 1,000,000 circumcisions.[119]
Hygiene, and infectious and chronic conditions
The American Academy of Pediatrics (1999) stated: "Circumcision has been suggested as an effective method of maintaining penile hygiene since the time of the Egyptian dynasties, but there is little evidence to affirm the association between circumcision status and optimal penile hygiene."[16]
An inflammation of the glans penis and foreskin is called balanoposthitis; that affecting the glans alone is called balanitis. Both conditions are usually treated with topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams. Although not as necessary as in the past, circumcision may be considered for recurrent or resistant cases.[144][145] Escala and Rickwood recommend against a policy of routine infant circumcision to avoid balanitis saying that the condition affects no more than 4% of boys, does not cause pathological phimosis, and in most cases is not serious.[146]
Fergusson studied 500 boys and found that by 8 years, the circumcised children had a rate of 11.1 problems per 100 children, and the uncircumcised children had a rate of 18.8 per 100. During infancy, circumcised children were found to have a significantly higher risk of problems than uncircumcised children, but after infancy the rate of penile problems was significantly higher among the uncircumcised. Fergusson et al. said that the great majority of penile problems were relatively minor (penile inflammation including balanitis, meatitis, and inflammation of the prepuce) and most (64%) were resolved after a single medical consultation.[147] Herzog and Alverez found the overall frequency of complications (including balanitis, irritation, adhesions, phimosis, and paraphimosis) to be higher among the uncircumcised children; again, most of the problems were minor.[148] In a study of 398 randomly selected dermatology students, Fakjian et al. reported: "Balanitis was diagnosed in 2.3% of circumcised men and in 12.5% of uncircumcised men."[149] In a study of 225 men, O'Farrell et al. reported: "Overall, circumcised men were less likely to be diagnosed with a STI/balanitis (51% and 35%, P = 0.021) than those non-circumcised."[150] Van Howe found that circumcised penes required more care in the first 3 months of life, and that circumcised boys are more likely to develop balanitis.[151]
The American Medical Association state that circumcision, properly performed, protects against the development of phimosis.[54] Rickwood and other authors have argued that many infant circumcisions are performed unnecessarily for developmental non-retractability of the prepuce rather than for pathological phimosis.[152][153] Metcalfe et al. stated that "Gairdner[118] and Oster[154] made a strong case for leaving boys uncircumcised, allowing the natural separation of the foreskin from the glans to take place gradually, and instructing boys in proper hygiene. This obviates the need for 'preventive' circumcision."[155] In a study to determine the most cost-effective treatment for phimosis, Van Howe concluded that using cream was 75% more cost-effective than circumcision at treating pathological phimosis.[156]
Urinary tract infections
A meta-analysis of 12 studies (one randomised controlled trial, four cohort studies and seven case-control studies) representing 402,908 children determined that circumcision was associated with a significantly reduced risk of urinary tract infection (UTI). However, the authors noted that only 1% of boys with normal urinary tract function experience a UTI, and the number-needed-to treat (number of circumcisions necessary) to prevent one urinary tract infection was calculated to be 111. Because haemorrhage and infection are the commonest complications of circumcision, occurring at rate of about 2%, assuming equal utility of benefits and harms, the authors concluded that the net clinical benefit of circumcision is only likely in boys at high risk of urinary tract infection (such as those with high grade vesicoureteral reflux or a history of recurrent UTIs, where the number needed to treat declined to 11 and 4, respectively).[157]
Some UTI studies have been criticized for not taking into account a high rate of UTI's among premature infants, who are usually not circumcised because of their fragile health status.[16] The AMA stated that “depending on the model employed, approximately 100 to 200 circumcisions would need to be performed to prevent 1 UTI," and noted one decision analysis model that concluded that circumcision was not justified as a preventative measure against UTI.[54]
Policies of various national medical associations
Most guidelines make a distinction between therapeutic and non-therapeutic circumcision. Therapeutic circumcision (where there is a medical need to circumcise) is rarely controversial. Neonatal circumcision is not considered medically necessary and is therefore categorised as non-therapeutic.[citation needed]
Australasia
The Royal Australasian College of Physicians (RACP) state that "after extensive review of the literature" they "reaffirm that there is no medical indication for routine neonatal circumcision". They also state that "if the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment." Additionally, the RACP state that there is an obligation to provide parents who request a circumcision for their child with accurate, up-to-date and unbiased information about the risks and benefits of circumcision, adding that "there is no evidence of benefit outweighing harm for circumcision as a routine procedure in the neonate."[56]
The Tasmanian President of the Australian Medical Association (AMA), Haydn Walters, has stated that the AMA would support a call to ban circumcision for non-medical, non-religious reasons.[161]
Canada
The Fetus and Newborn Committee of the Canadian Paediatric Society posted "Neonatal circumcision revisited" in 1996 and "Circumcision: Information for Parents" in November 2004.[81] The 1996 position statement says that "circumcision of newborns should not be routinely performed," (a statement with which the Royal Australasian College of Physicians concurs), and the 2004 advice to parents says it "does not recommend circumcision for newborn boys. Many pediatricians no longer perform circumcisions."[55]
United Kingdom
There is a spectrum of views within the British Medical Association's (BMA) membership about whether non-therapeutic male circumcision is a beneficial, neutral or harmful procedure or whether it is superfluous, and whether it should ever be done on a child who is not capable of deciding for himself. Moreover, the Association states that “there is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure. At present, the medical literature on the health, including sexual health, implications of circumcision is contradictory, and often subject to claims of bias in research.”[57] As a general rule, the BMA believe that "parents should be entitled to make choices about how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices." They also state that "both parents...must give consent for non-therapeutic circumcision", and that parents and children should be provided with up-to-date written information about the risks involved.[57]
According to the BMA, circumcision for medical purposes should only be used where less invasive procedures are either unavailable or not as effective. They state that "to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate." Furthermore, the BMA believe that children who are capable of expressing a view should be involved in the decision-making process with regard to their own circumcision, and their views should be taken into account. The BMA state that they "cannot envisage a situation in which it is ethically acceptable to circumcise a competent, informed young person who consistently refuses the procedure."[57]
The BMA state that parents should be informed about the lack of consensus within the medical profession with regard to the potential health benefits of non-therapeutic circumcision, adding that they consider the evidence for such benefits to be insufficient as the sole reason for carrying out a circumcision.[57]
United States
The American Academy of Pediatrics (1999) stated: "Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision, in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child."[16] The AAP recommends that if parents choose to circumcise, analgesia should be used to reduce pain associated with circumcision. It states that circumcision should only be performed on newborns who are stable and healthy.[16]
The American Medical Association supports the AAP's 1999 circumcision policy statement with regard to non-therapeutic circumcision, which they define as the non-religious, non-ritualistic, not medically necessary, elective circumcision of male newborns. They state that "policy statements issued by professional societies representing Australian, Canadian, and American pediatricians do not recommend routine circumcision of male newborns."[54]
The American Academy of Family Physicians (2007) recognizes the controversy surrounding circumcision and recommends that physicians "discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn son."[162]
The American Urological Association (2007) stated that neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks.[163]
History of circumcision
It has been variously proposed that circumcision began as a religious sacrifice, as a rite of passage marking a boy's entrance into adulthood, as a form of sympathetic magic to ensure virility, as a means of suppressing sexual pleasure or to increase a man's attractiveness to women, or as an aid to hygiene where regular bathing was impractical, among other possibilities. Immerman et al. suggest that circumcision causes lowered sexual arousal of pubescent males, and hypothesize that this was a competitive advantage to tribes practicing circumcision, leading to its spread regardless of whether the people understood this.[164] It is possible that circumcision arose independently in different cultures for different reasons.
Family circumcision set and trunk, ca. eighteenth century Wooden box covered in cow hide with silver implements: silver trays, clip, pointer, silver flask, spice vessel.
The oldest documentary evidence for circumcision comes from ancient Egypt.[165] Circumcision was common, although not universal, among ancient Semitic peoples.[166] In the aftermath of the conquests of Alexander the Great, however, Greek dislike of circumcision (they regarded a man as truly "naked" only if his prepuce was retracted) led to a decline in its incidence among many peoples that had previously practiced it.[167]
Circumcision has ancient roots among several ethnic groups in sub-equatorial Africa, and is still performed on adolescent boys to symbolize their transition to warrior status or adulthood.[168]
Circumcision in the English-speaking world
Infant circumcision was taken up in the United States, Australia and the English-speaking parts of Canada, South Africa, New Zealand and to a lesser extent in the United Kingdom. There are several hypotheses to explain why infant circumcision was accepted in the United States about the year 1900. The germ theory of disease elicited an image of the human body as a conveyance for many dangerous germs, making the public "germ phobic" and suspicious of dirt and bodily secretions. The penis became "dirty" by association with its function, and from this premise circumcision was seen as preventative medicine to be practiced universally.[169] In the view of many practitioners at the time, circumcision was a method of treating and preventing masturbation.[169] Aggleton wrote that John Kellogg viewed male circumcision in this way, and further "advocated an unashamedly punitive approach."[170] Circumcision was also said to protect against syphilis,[171] phimosis, paraphimosis, balanitis, and "excessive venery" (which was believed to produce paralysis).[169] Gollaher states that physicians advocating circumcision in the late nineteenth century expected public skepticism, and refined their arguments to overcome it.[169]
Although it is difficult to determine historical circumcision rates, one estimate of infant circumcision rates in the United States holds that 32% of newborn American boys were being circumcised in 1933.[98] Laumann et al. reported that the prevalence of circumcision among US-born males was approximately 70%, 80%, 85%, and 77% for those born in 1945, 1955, 1965, and 1971 respectively.[98] Xu et al. reported that the prevalence of circumcision among US-born males was 91% for males born in the 1970s and 84% for those born in the 1980s.[172] Between 1981 and 1999, National Hospital Discharge Survey data from the National Center for Health Statistics demonstrated that the infant circumcision rate remained relatively stable within the 60% range, with a minimum of 60.7% in 1988 and a maximum of 67.8% in 1995.[173] A 1987 study found that the most prominent reasons US parents choose circumcision were "concerns about the attitudes of peers and their sons' self concept in the future," rather than medical concerns.[174] However, a later study speculated that an increased recognition of the potential benefits of neonatal circumcision may have been responsible for the observed increase in the US rate between 1988 and 2000.[175] A report by the Agency for Healthcare Research and Quality placed the 2005 national circumcision rate at 56%.[176]
In 1949, the United Kingdom's newly-formed National Health Service removed infant circumcision from its list of covered services, and circumcision has since been an out-of-pocket cost to parents. As a result, prevalence in the UK is age-graded, with 12% of those aged 16-19 years circumcised and 20% of those aged 40-44 years,[177] and the proportion of newborns circumcised in England and Wales has fallen to less than one percent.
The circumcision rate has declined sharply in Australia since the 1970s, leading to an age-graded fall in prevalence, with a 2000-01 survey finding 32% of those aged 16-19 years circumcised, 50% for 20-29 years and 64% for those aged 30-39 years.[178][179]
In Canada, individual provincial health services began delisting circumcision in the 1980s.[citation needed]
Prevalence of circumcision
Estimates of the proportion of males that are circumcised worldwide vary from one-sixth[104] to a third.[180] The WHO has estimated that 664,500,000 males aged 15 and over are circumcised (30% global prevalence), with almost 70% of these being Muslim.[8] Circumcision is most prevalent in the Muslim world, parts of South East Asia, Africa, the United States, The Philippines, Israel, and South Korea. It is relatively rare in Europe, Latin America, parts of Southern Africa, and most of Asia and Oceania. Prevalence is near-universal in the Middle East and Central Asia.[8] The WHO states that "there is generally little non-religious circumcision in Asia, with the exceptions of the Republic of Korea and the Philippines".[8] The WHO presents a map of estimated prevalence in which the level is generally low (< 20%) across Europe,[8] and Klavs et al. report findings that "support the notion that the prevalence is low in Europe".[181] In Latin America, prevalence is universally low.[182] Estimates for individual countries include Spain[183], Colombia[183] and Denmark[184] less than 2%, Finland[185] and Brazil[183] 7%, Taiwan[186] 9%, Thailand[183] 13%, New Zealand[187] less than 20% and Australia[179] 58.7%.
The WHO estimates prevalence in the United States and Canada at 75% and 30%, respectively.[8] Prevalence in Africa varies from less than 20% in some southern African countries to near universal in North and West Africa.
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Lobotomy
Friday, May 29, 2009
Oophorectomy
PROCEDURE OF THE DAY
Oophorectomy
Oophorectomy (or ovariectomy) is the surgical removal of an ovary or ovaries. In the case of non-human animals, it is also called spaying and is a form of sterilization. Removal of the ovaries in women is the biological equivalent of castration in males, and the term is occasionally used in the medical literature instead of oophorectomy.
In the case of humans, oophorectomies are most often performed due to diseases such as ovarian cysts or cancer; prophylactically to reduce the chances of developing ovarian cancer or breast cancer; or in conjunction with removal of the uterus.
The removal of an ovary together with a Fallopian tube is called salpingo-oophorectomy or bilateral salpingo-oophorectomy if both ovaries and tubes are removed. Oophorectomy and salpingo-oophorectomy are not common forms of birth control in humans; more usual is tubal ligation, in which the Fallopian tubes are blocked but the ovaries remain intact. In many cases, surgical removal of the ovaries is performed concurrently with a hysterectomy. The surgery is then called "ovariohysterectomy" casually or "total abdominal hysterectomy with bilateral salpingo-oophorectomy" (sometimes abbreviated TAH-BSO), the more correct medical term. However, the term "hysterectomy" is often used colloquially yet incorrectly to refer to removal of any parts of the female reproductive system, including just the ovaries.
Hormone replacement
In general, hormone replacement therapy is somewhat controversial due to the known carcinogenic and coagulative properties of estrogen; however, many physicians and patients feel the benefits outweigh the risks in women who may face serious health and quality of life issues as a consequence of early surgical menopause. The ovarian hormones of estrogen, progesterone, and testosterone are involved in the regulation of hundreds of bodily functions; it is believed by some doctors that hormone therapy programs mitigate surgical menopause side effects such as increased risk of cardiovascular disease [1], and female sexual dysfunction [2]. There are many options for hormone replacement currently available and a considerable controversy.
Benefits
Reduced breast cancer risk
Women with a risk of breast cancer, especially those women with mutated BRCA1 and/or BRCA2 genes, have been shown to have a significantly reduced risk of developing breast cancer after prophylactic oophorectomy[3]. In addition, removal of the uterus in conjunction with prophylactic oophorectomy allows estrogen-based HRT to be prescribed to aid the woman through her transition into surgical menopause, instead of mixed hormone HRT, which has a significant contribution to breast cancer as well[4].
Reduced ovarian cancer risk
Women with a risk of ovarian cancer, especially those women with mutated BRCA1 and/or BRCA2 genes, have been shown to have a significantly reduced risk of developing ovarian cancer after prophylactic oophorectomy. Risk is not reduced to zero, however, because the possibility of developing primary peritoneal cancer (ovarian cancer that begins outside the ovaries) does persist.
Reduced problems of endometriosis
In rare cases, oophorectomy can be used to treat endometriosis. This is done to remove a source of hormones that fuel uterine lining growth, thus reducing the overgrowth responsible for endometriosis. Oophorectomy for endometriosis is usually a last-resort surgery, since hormonal agonists such as Lupron are usually prescribed first to alter the hormonal cycle. Oophorectomy for endometriosis is often done in conjunction with a hysterectomy as a final shot at removing all traces of endometriosis in cases where non-surgical treatments such as hormonal agonists have failed to stop the uterine overgrowth.
Ovarian cyst removal not involving total oophorectomy is often used to treat milder cases of endometriosis when non-surgical hormonal treatments fail to stop cyst formation. Removal of ovarian cysts through partial oophorectomy is also used to treat extreme pelvic pain from chronic hormonal-related pelvic problems.
Premenstrual Dysphoric Disorder
Oophorectomy or the onset of menopause are the only complete cures for PMDD. However, hormone therapy is usually then needed to mimic natural hormone levels.
Risks
Longevity Risk
Removal of ovaries causes hormonal changes and symptoms similar to, but generally more severe than, menopause. Women who have had an oophorectomy are usually encouraged to take hormone replacement drugs to prevent other conditions often associated with menopause. Women younger than 45 who have had their ovaries removed face a mortality risk 170% higher than women who have retained their ovaries. [5]. Retaining the ovaries when a hysterectomy is performed is associated with greater longevity.[6]. However, hormone therapy is commonly believed by many doctors to mitigate the mortality risks of oophorectomy [7].
Women who have had bilateral oophorectomy surgeries lose most of their ability to produce the hormones estrogen and progesterone, and lose about half of their ability to produce testosterone, and subsequently enter what is known as "surgical menopause" (as opposed to normal menopause, which occurs naturally in women as part of the aging process). "Surgical menopause" differs from naturally occurring menopause in several respects: Surgical menopause is the result of surgery, while menopause is a natural event. A menopausal woman has intact functional female organs, a woman with surgical menopause does not. In natural menopause the ovaries generally continue to produce low levels of hormones, while in surgical menopause the ovaries and their hormones are absent, which can explain why surgical menopause is generally accompanied by a more sudden and severe onset of symptoms than natural menopause, symptoms which may continue until natural age of menopause arrives [8]. These symptoms are commonly addressed through hormone therapy, utilizing various forms of estrogen, testosterone, progesterone or a combination of them.
Cardiovascular Risk
When the ovaries are removed a woman is at a seven times greater risk of cardiovascular disease, [9][10][11] [12] but the mechanisms are not precisely known. The hormone production of the ovaries currently cannot be sufficiently mimicked by drug therapy. The ovaries produce hormones a woman needs throughout her entire life, in the quantity they are needed, at the time they are needed, and released directly into the blood stream in a continuous fashion, in response to and as part of the complex endocrine system.
Bone Density Risk
In women under the age of 50 who have undergone oophorectomy, hormone supplements (usually estrogen) are often prescribed as part of hormone replacement therapy (HRT) to offset the negative effects of sudden hormonal loss (most notably an increased risk for early-onset osteoporosis) as well as menopausal problems like hot flushes (also called "hot flashes") that are usually more severe than those experienced by women undergoing natural menopause.
Some studies have found that increased bone loss or fracture risk is associated with oophorectomy. [13]. [14]. [15]. [16] [17] Reduced levels of testosterone in women is predictive of height loss, which may occur as a result of reduced bone density,[18].
Sexuality Risk
Oophorectomy very rarely impacts sexuality in women, it does not greatly reduce or eliminate the ability to have an orgasm, however occasionally there is a lowering of sexual desire. This reduction is greater than that seen in women undergoing natural menopause [19]. Some of these problems can be addressed by taking hormone replacement. Increased testosterone levels in women are associated with a greater sense of sexual desire, and oophorectomy greatly reduces testosterone levels. [20]. Reduction in sexual well-being was reported in women who had been given a hysterectomy with both ovaries removed.[21].
Statistics
According to the Center for Disease Control, 454,000 women in the United States underwent this type of operation in 2004.
Technique
When performed alone (without hysterectomy), an oophorectomy is generally performed by abdominal laparotomy.
Managing side effects of prophylactic oophorectomy
Non-hormonal treatments
The side effects of oophorectomy may be alleviated by medicines other than hormonal replacement. Non-hormonal biphosphonates (such as Fosamax and Actonel) increase bone strength and are available as once-a-week pills. Low-dose Selective Serotonin Reuptake Inhibitors (e.g. Paxil, Prozac) alleviate vasomotor menopausal symptoms, i.e. "hot flashes".[22]
Hormonal treatments
Short-term hormone replacement with estrogen, in high-risk BRCA mutation carriers, was not shown to increase the risk of breast cancer in women who are post-oophorectomic. The results were published in JCO in 2004 and the conclusions were based on a computerized simulation using models of risk and benefit, a lower level of data than a randomized trial per se.[23] This result can probably be generalized to other women at high risk in whom short term (i.e., one or two year) treatment with estrogen for hot flashes, may be acceptable.
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Circumcision
Oophorectomy
Oophorectomy (or ovariectomy) is the surgical removal of an ovary or ovaries. In the case of non-human animals, it is also called spaying and is a form of sterilization. Removal of the ovaries in women is the biological equivalent of castration in males, and the term is occasionally used in the medical literature instead of oophorectomy.
In the case of humans, oophorectomies are most often performed due to diseases such as ovarian cysts or cancer; prophylactically to reduce the chances of developing ovarian cancer or breast cancer; or in conjunction with removal of the uterus.
The removal of an ovary together with a Fallopian tube is called salpingo-oophorectomy or bilateral salpingo-oophorectomy if both ovaries and tubes are removed. Oophorectomy and salpingo-oophorectomy are not common forms of birth control in humans; more usual is tubal ligation, in which the Fallopian tubes are blocked but the ovaries remain intact. In many cases, surgical removal of the ovaries is performed concurrently with a hysterectomy. The surgery is then called "ovariohysterectomy" casually or "total abdominal hysterectomy with bilateral salpingo-oophorectomy" (sometimes abbreviated TAH-BSO), the more correct medical term. However, the term "hysterectomy" is often used colloquially yet incorrectly to refer to removal of any parts of the female reproductive system, including just the ovaries.
Hormone replacement
In general, hormone replacement therapy is somewhat controversial due to the known carcinogenic and coagulative properties of estrogen; however, many physicians and patients feel the benefits outweigh the risks in women who may face serious health and quality of life issues as a consequence of early surgical menopause. The ovarian hormones of estrogen, progesterone, and testosterone are involved in the regulation of hundreds of bodily functions; it is believed by some doctors that hormone therapy programs mitigate surgical menopause side effects such as increased risk of cardiovascular disease [1], and female sexual dysfunction [2]. There are many options for hormone replacement currently available and a considerable controversy.
Benefits
Reduced breast cancer risk
Women with a risk of breast cancer, especially those women with mutated BRCA1 and/or BRCA2 genes, have been shown to have a significantly reduced risk of developing breast cancer after prophylactic oophorectomy[3]. In addition, removal of the uterus in conjunction with prophylactic oophorectomy allows estrogen-based HRT to be prescribed to aid the woman through her transition into surgical menopause, instead of mixed hormone HRT, which has a significant contribution to breast cancer as well[4].
Reduced ovarian cancer risk
Women with a risk of ovarian cancer, especially those women with mutated BRCA1 and/or BRCA2 genes, have been shown to have a significantly reduced risk of developing ovarian cancer after prophylactic oophorectomy. Risk is not reduced to zero, however, because the possibility of developing primary peritoneal cancer (ovarian cancer that begins outside the ovaries) does persist.
Reduced problems of endometriosis
In rare cases, oophorectomy can be used to treat endometriosis. This is done to remove a source of hormones that fuel uterine lining growth, thus reducing the overgrowth responsible for endometriosis. Oophorectomy for endometriosis is usually a last-resort surgery, since hormonal agonists such as Lupron are usually prescribed first to alter the hormonal cycle. Oophorectomy for endometriosis is often done in conjunction with a hysterectomy as a final shot at removing all traces of endometriosis in cases where non-surgical treatments such as hormonal agonists have failed to stop the uterine overgrowth.
Ovarian cyst removal not involving total oophorectomy is often used to treat milder cases of endometriosis when non-surgical hormonal treatments fail to stop cyst formation. Removal of ovarian cysts through partial oophorectomy is also used to treat extreme pelvic pain from chronic hormonal-related pelvic problems.
Premenstrual Dysphoric Disorder
Oophorectomy or the onset of menopause are the only complete cures for PMDD. However, hormone therapy is usually then needed to mimic natural hormone levels.
Risks
Longevity Risk
Removal of ovaries causes hormonal changes and symptoms similar to, but generally more severe than, menopause. Women who have had an oophorectomy are usually encouraged to take hormone replacement drugs to prevent other conditions often associated with menopause. Women younger than 45 who have had their ovaries removed face a mortality risk 170% higher than women who have retained their ovaries. [5]. Retaining the ovaries when a hysterectomy is performed is associated with greater longevity.[6]. However, hormone therapy is commonly believed by many doctors to mitigate the mortality risks of oophorectomy [7].
Women who have had bilateral oophorectomy surgeries lose most of their ability to produce the hormones estrogen and progesterone, and lose about half of their ability to produce testosterone, and subsequently enter what is known as "surgical menopause" (as opposed to normal menopause, which occurs naturally in women as part of the aging process). "Surgical menopause" differs from naturally occurring menopause in several respects: Surgical menopause is the result of surgery, while menopause is a natural event. A menopausal woman has intact functional female organs, a woman with surgical menopause does not. In natural menopause the ovaries generally continue to produce low levels of hormones, while in surgical menopause the ovaries and their hormones are absent, which can explain why surgical menopause is generally accompanied by a more sudden and severe onset of symptoms than natural menopause, symptoms which may continue until natural age of menopause arrives [8]. These symptoms are commonly addressed through hormone therapy, utilizing various forms of estrogen, testosterone, progesterone or a combination of them.
Cardiovascular Risk
When the ovaries are removed a woman is at a seven times greater risk of cardiovascular disease, [9][10][11] [12] but the mechanisms are not precisely known. The hormone production of the ovaries currently cannot be sufficiently mimicked by drug therapy. The ovaries produce hormones a woman needs throughout her entire life, in the quantity they are needed, at the time they are needed, and released directly into the blood stream in a continuous fashion, in response to and as part of the complex endocrine system.
Bone Density Risk
In women under the age of 50 who have undergone oophorectomy, hormone supplements (usually estrogen) are often prescribed as part of hormone replacement therapy (HRT) to offset the negative effects of sudden hormonal loss (most notably an increased risk for early-onset osteoporosis) as well as menopausal problems like hot flushes (also called "hot flashes") that are usually more severe than those experienced by women undergoing natural menopause.
Some studies have found that increased bone loss or fracture risk is associated with oophorectomy. [13]. [14]. [15]. [16] [17] Reduced levels of testosterone in women is predictive of height loss, which may occur as a result of reduced bone density,[18].
Sexuality Risk
Oophorectomy very rarely impacts sexuality in women, it does not greatly reduce or eliminate the ability to have an orgasm, however occasionally there is a lowering of sexual desire. This reduction is greater than that seen in women undergoing natural menopause [19]. Some of these problems can be addressed by taking hormone replacement. Increased testosterone levels in women are associated with a greater sense of sexual desire, and oophorectomy greatly reduces testosterone levels. [20]. Reduction in sexual well-being was reported in women who had been given a hysterectomy with both ovaries removed.[21].
Statistics
According to the Center for Disease Control, 454,000 women in the United States underwent this type of operation in 2004.
Technique
When performed alone (without hysterectomy), an oophorectomy is generally performed by abdominal laparotomy.
Managing side effects of prophylactic oophorectomy
Non-hormonal treatments
The side effects of oophorectomy may be alleviated by medicines other than hormonal replacement. Non-hormonal biphosphonates (such as Fosamax and Actonel) increase bone strength and are available as once-a-week pills. Low-dose Selective Serotonin Reuptake Inhibitors (e.g. Paxil, Prozac) alleviate vasomotor menopausal symptoms, i.e. "hot flashes".[22]
Hormonal treatments
Short-term hormone replacement with estrogen, in high-risk BRCA mutation carriers, was not shown to increase the risk of breast cancer in women who are post-oophorectomic. The results were published in JCO in 2004 and the conclusions were based on a computerized simulation using models of risk and benefit, a lower level of data than a randomized trial per se.[23] This result can probably be generalized to other women at high risk in whom short term (i.e., one or two year) treatment with estrogen for hot flashes, may be acceptable.
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Circumcision
Thursday, May 28, 2009
Reduction Mammoplasty
PROCEDURE OF THE DAY
Reduction Mammoplasty
Breast reduction or reduction mammoplasty is an outpatient surgical procedure[1] which involves the reduction in the size of breasts by excising fat, skin, and glandular tissue; it may also involve a procedure to counteract drooping of the breasts. As with breast augmentation, this procedure is typically performed on women, but may also be performed on men afflicted by gynecomastia.
The surgery, which the Food and Drug Administration has called "good medicine", is quickly gaining popularity. In 2005, over 113,000 women had breast reductions, an increase of 11 percent from 2004.[2]
Candidates
Breast reduction surgery is oriented toward women with large, pendulous breasts, especially gigantomastia, since the weight of their breasts may cause chronic pain of the head, neck, back, and shoulders, plus circulation and breathing problems. The weight may also cause discomfort as a result of brassiere straps abrading or irritating the skin.[2] For these reasons, the surgery is usually covered by insurance.[3] Even if physical discomfort is not a problem, some women feel awkward with the enormity of their breasts in proportion to the rest of their relatively smaller bodies. Except in unusual cases, this procedure is performed on individuals with fully-developed breasts, and it is not typically recommended for women who desire to breastfeed.
Males with common condition of gynecomastia may feel embarrassed and upset with their condition, usually developed during adolescence. They may get the surgery for restored confidence.[4] The surgical methods employed may vary depending on whether the breasts in the male patient are caused by adipose (fatty) or glandular tissue, and the degree to which any glandular tissue extends laterally along the sides of the torso.
A few celebrities are known for receiving breast reductions, such as Drew Barrymore,[5] Soleil Moon Frye,[6] Queen Latifah,[7], Sharon Osbourne[8], and Kerry Katona.[9]
Procedure
Doctors almost always perform breast reductions while the patient is under general anesthesia. During pre-operative visits, the doctor and patient may decide on new, usually higher, positions for the areolas and nipples.
For males, excess tissue may simply be removed through a tiny incision in each breast. This leaves minimal scarring.[4]
Patients may take a few weeks for initial recovery, however it may take from six months to a year for the body to completely adjust to the new breast size. Some women may experience discomfort during their initial menstruation following the surgery due to the breasts swelling.
Techniques
The traditional popular technique in North America bases the blood supply to the nipple and areola complex (NAC) from a central and inferiorly based attachment to the chest wall (an "inferior pedicle" or "central mound" technique), with variations of orientations of such pedicles described.[10] Better understanding of anatomy in terms of innervation to the NAC has made it more likely to leave both nipple sensitivity and capability to lactate for the patient as compared to other techniques of the past.[11] It is now being studied and debated as to which of the techniques results in a better quality of life for the patient in the long run.[10] Liposuction has been used as an adjunct to other breast reduction procedures for quite some time, but liposuction only techniques are not widely performed. All of the breast reduction techniques produce some degree of breast lift, but have a tendency to settle and stretch out the inferior skin envelope over time.
A comparison of post-surgery incision lines from the two most popular techniques
Inferior pedicle technique
The inferior pedicle technique, sometimes also known as a keyhole, inverted-T, or "Wise pattern" reduction, involves an anchor-shaped incision which circles the areola. The incision extends downward, following the natural curve of the breast. Excess glandular tissue, fat, and skin is removed. Next, the nipple and areola are moved into their new higher position.[12] A drawback of this technique is sometimes "square" looking breasts, but this is a common option for women with the largest, droopiest breasts. This is the most commonly performed technique in North America and produces predictable outcomes with larger reductions. Inferior pedicle techniques can also be performed through shorter scar incisions in some patients.
Vertical scar technique
The vertical scar techniques are gaining popularity in the United States due to their shorter scarring and projecting shape post-surgery. These types of procedures can involve the use of superior, inferior, medial or laterally based pedicles to the NAC. As compared to traditional incisions, they may have a limited or absent horizontal component. These procedures are best suited to smaller reductions with less excess skin to limit the scar length. Advantages include increased projection by the gathering of tissue medially, shorter scar length, and quicker surgery times. This technique keeps its results the best in the long term.[13] The breast is reduced through removal of the lateral and inferior tissues, leaving the upper pole mostly untouched.[14]
Horizontal scar technique
Horizontal scar techniques involve the use of a scar along the inframammary fold and a round cutout for the NAC. These procedures typically require a inferior or inferior-lateral pedical like traditional "Wise pattern" surgeries but eschew the vertical wedge excision. They permit a shorter scar option in women who are too large for vertical scar techniques. Advantages include the absence of a scar on the visible meridian of the breast and better scarring of the NAC inset. Disadvantages are the potential for "boxy" shaped breasts and poorer scarring that can be produced along the IMF.
Liposuction only technique
The liposuction only technique is used for women with breasts that are not quite as large as with the other procedures or in patients whom are anesthesia risks for longer procedures. For the best outcomes, women who choose this procedure have fatty, non-dense breast tissue with good skin and little ptosis (droop). As few women with larger breast possess those characteristics, the widespread use of this technique may be limited. The result is not as drastic as the other techniques, but it involves a quicker healing time and little scarring.[15] This is a technique typically used in conjunction with some direct excision of dense tissue for male gynecomastia surgery.
Free nipple graft technique
The free nipple graft technique is used primarily for high risk patients of ischemia to the NAC to reduce the chance of sloughing it postoperatively. Typical candidates would include diabetics, smokers, longer breasts approaching 20 cm from the IMF to the nipple, and breasts with significantly larger then normal resection requirements. In this procedure, the areola and nipple are completely removed for relocation and replaced as a skin graft higher on the breast. In these cases, sensation from the areola area will be lost and it eliminates the ability for lactation. This technique is sometimes used during surgery or postoperatively if the NAC viability is questionable. By eliminating the requirement for a pedical, this procedure allows significantly greater amounts of tissue to be removed safely.
Results
Reduction mammoplasty affords the recipient smaller, lighter, and firmer breasts. The surgeon may also reduce the size of and change the shape of the areola or nipples. Both men and women typically have restored confidence, as well.[4] It is often mentioned that patients who have received breast reductions are the happiest and most satisfied of all plastic surgery recipients.[3][2]
Risks
Possible issues include difficulty breast feeding, scarring, asymmetry, delayed wound healing, altered nipple sensation, fluid retention in the breast, altered erogenous function, and late changes in shape and recurrent ptosis (drooping.)
It may impair the likelihood of breastfeeding success due to the surgical disruption to the lactiferous duct system.[16][17] However, a number of studies have demonstrated a similar ability to breast feed when breast reduction patients are compared to control groups.[18][19][20]
Scarring from this procedure may be extensive and permanent. Initially, the scars are lumpy and red, but they gradually subside into their final smaller sizes as thin lines, slightly discolored. Though permanent, the surgeon can make the scars inconspicuous to the point that even low-cut tops may be worn without visible scars.
Cancer Prevention
Although not advocated as a cancer risk reducing procedure, a woman's risk of subsequently developing breast cancer will be reduced proportionately to the amount of breast tissue left.[citation needed]
The surgery can also make mammograms easier, since it may be difficult to get a decent mammogram reading with a great deal of excess breast tissue. Therefore, with less tissue, it can be easier for a doctors to get and interpret the results of a mammogram.[2] However, it is still typically recommended that patients receive new baseline mammograms 6 to 8 months after breast reduction to accommodate expected radiographic changes and give a new basis to which future imaging studies can be compared.
VIDEO
*None*
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Oophorectomy
Reduction Mammoplasty
Breast reduction or reduction mammoplasty is an outpatient surgical procedure[1] which involves the reduction in the size of breasts by excising fat, skin, and glandular tissue; it may also involve a procedure to counteract drooping of the breasts. As with breast augmentation, this procedure is typically performed on women, but may also be performed on men afflicted by gynecomastia.
The surgery, which the Food and Drug Administration has called "good medicine", is quickly gaining popularity. In 2005, over 113,000 women had breast reductions, an increase of 11 percent from 2004.[2]
Candidates
Breast reduction surgery is oriented toward women with large, pendulous breasts, especially gigantomastia, since the weight of their breasts may cause chronic pain of the head, neck, back, and shoulders, plus circulation and breathing problems. The weight may also cause discomfort as a result of brassiere straps abrading or irritating the skin.[2] For these reasons, the surgery is usually covered by insurance.[3] Even if physical discomfort is not a problem, some women feel awkward with the enormity of their breasts in proportion to the rest of their relatively smaller bodies. Except in unusual cases, this procedure is performed on individuals with fully-developed breasts, and it is not typically recommended for women who desire to breastfeed.
Males with common condition of gynecomastia may feel embarrassed and upset with their condition, usually developed during adolescence. They may get the surgery for restored confidence.[4] The surgical methods employed may vary depending on whether the breasts in the male patient are caused by adipose (fatty) or glandular tissue, and the degree to which any glandular tissue extends laterally along the sides of the torso.
A few celebrities are known for receiving breast reductions, such as Drew Barrymore,[5] Soleil Moon Frye,[6] Queen Latifah,[7], Sharon Osbourne[8], and Kerry Katona.[9]
Procedure
Doctors almost always perform breast reductions while the patient is under general anesthesia. During pre-operative visits, the doctor and patient may decide on new, usually higher, positions for the areolas and nipples.
For males, excess tissue may simply be removed through a tiny incision in each breast. This leaves minimal scarring.[4]
Patients may take a few weeks for initial recovery, however it may take from six months to a year for the body to completely adjust to the new breast size. Some women may experience discomfort during their initial menstruation following the surgery due to the breasts swelling.
Techniques
The traditional popular technique in North America bases the blood supply to the nipple and areola complex (NAC) from a central and inferiorly based attachment to the chest wall (an "inferior pedicle" or "central mound" technique), with variations of orientations of such pedicles described.[10] Better understanding of anatomy in terms of innervation to the NAC has made it more likely to leave both nipple sensitivity and capability to lactate for the patient as compared to other techniques of the past.[11] It is now being studied and debated as to which of the techniques results in a better quality of life for the patient in the long run.[10] Liposuction has been used as an adjunct to other breast reduction procedures for quite some time, but liposuction only techniques are not widely performed. All of the breast reduction techniques produce some degree of breast lift, but have a tendency to settle and stretch out the inferior skin envelope over time.
A comparison of post-surgery incision lines from the two most popular techniques
Inferior pedicle technique
The inferior pedicle technique, sometimes also known as a keyhole, inverted-T, or "Wise pattern" reduction, involves an anchor-shaped incision which circles the areola. The incision extends downward, following the natural curve of the breast. Excess glandular tissue, fat, and skin is removed. Next, the nipple and areola are moved into their new higher position.[12] A drawback of this technique is sometimes "square" looking breasts, but this is a common option for women with the largest, droopiest breasts. This is the most commonly performed technique in North America and produces predictable outcomes with larger reductions. Inferior pedicle techniques can also be performed through shorter scar incisions in some patients.
Vertical scar technique
The vertical scar techniques are gaining popularity in the United States due to their shorter scarring and projecting shape post-surgery. These types of procedures can involve the use of superior, inferior, medial or laterally based pedicles to the NAC. As compared to traditional incisions, they may have a limited or absent horizontal component. These procedures are best suited to smaller reductions with less excess skin to limit the scar length. Advantages include increased projection by the gathering of tissue medially, shorter scar length, and quicker surgery times. This technique keeps its results the best in the long term.[13] The breast is reduced through removal of the lateral and inferior tissues, leaving the upper pole mostly untouched.[14]
Horizontal scar technique
Horizontal scar techniques involve the use of a scar along the inframammary fold and a round cutout for the NAC. These procedures typically require a inferior or inferior-lateral pedical like traditional "Wise pattern" surgeries but eschew the vertical wedge excision. They permit a shorter scar option in women who are too large for vertical scar techniques. Advantages include the absence of a scar on the visible meridian of the breast and better scarring of the NAC inset. Disadvantages are the potential for "boxy" shaped breasts and poorer scarring that can be produced along the IMF.
Liposuction only technique
The liposuction only technique is used for women with breasts that are not quite as large as with the other procedures or in patients whom are anesthesia risks for longer procedures. For the best outcomes, women who choose this procedure have fatty, non-dense breast tissue with good skin and little ptosis (droop). As few women with larger breast possess those characteristics, the widespread use of this technique may be limited. The result is not as drastic as the other techniques, but it involves a quicker healing time and little scarring.[15] This is a technique typically used in conjunction with some direct excision of dense tissue for male gynecomastia surgery.
Free nipple graft technique
The free nipple graft technique is used primarily for high risk patients of ischemia to the NAC to reduce the chance of sloughing it postoperatively. Typical candidates would include diabetics, smokers, longer breasts approaching 20 cm from the IMF to the nipple, and breasts with significantly larger then normal resection requirements. In this procedure, the areola and nipple are completely removed for relocation and replaced as a skin graft higher on the breast. In these cases, sensation from the areola area will be lost and it eliminates the ability for lactation. This technique is sometimes used during surgery or postoperatively if the NAC viability is questionable. By eliminating the requirement for a pedical, this procedure allows significantly greater amounts of tissue to be removed safely.
Results
Reduction mammoplasty affords the recipient smaller, lighter, and firmer breasts. The surgeon may also reduce the size of and change the shape of the areola or nipples. Both men and women typically have restored confidence, as well.[4] It is often mentioned that patients who have received breast reductions are the happiest and most satisfied of all plastic surgery recipients.[3][2]
Risks
Possible issues include difficulty breast feeding, scarring, asymmetry, delayed wound healing, altered nipple sensation, fluid retention in the breast, altered erogenous function, and late changes in shape and recurrent ptosis (drooping.)
It may impair the likelihood of breastfeeding success due to the surgical disruption to the lactiferous duct system.[16][17] However, a number of studies have demonstrated a similar ability to breast feed when breast reduction patients are compared to control groups.[18][19][20]
Scarring from this procedure may be extensive and permanent. Initially, the scars are lumpy and red, but they gradually subside into their final smaller sizes as thin lines, slightly discolored. Though permanent, the surgeon can make the scars inconspicuous to the point that even low-cut tops may be worn without visible scars.
Cancer Prevention
Although not advocated as a cancer risk reducing procedure, a woman's risk of subsequently developing breast cancer will be reduced proportionately to the amount of breast tissue left.[citation needed]
The surgery can also make mammograms easier, since it may be difficult to get a decent mammogram reading with a great deal of excess breast tissue. Therefore, with less tissue, it can be easier for a doctors to get and interpret the results of a mammogram.[2] However, it is still typically recommended that patients receive new baseline mammograms 6 to 8 months after breast reduction to accommodate expected radiographic changes and give a new basis to which future imaging studies can be compared.
VIDEO
*None*
NEXT UP
Oophorectomy
Wednesday, May 27, 2009
Laparotomy
PROCEDURE OF THE DAY
Laparotomy
A laparotomy is a surgical procedure involving an incision through the abdominal wall to gain access into the abdominal cavity. It is also known as coeliotomy.
Terminology
In diagnostic laparotomy (most often referred to as an exploratory laparotomy and abbreviated Ex-Lap), the nature of the disease is unknown, and laparotomy is deemed the best way to identify the cause.
In therapeutic laparotomy, a cause has been identified (e.g. peptic ulcer, colon cancer) and laparotomy is required for its therapy.
Usually, only exploratory laparotomy is referred to as a surgical operation by itself; and when a specific operation is already planned, laparotomy is considered merely the first step of the procedure.
Spaces accessed
Depending on incision placement, it may give access to any abdominal organ or space, and is the first step in any major diagnostic or therapeutic surgical procedure of these organs, which include:
* the lower part of the digestive tract (the stomach, duodenum, jejunum, ileum and colon)
* the liver, pancreas and spleen
* the bladder
* the female reproductive organs (the uterus and ovaries)
* the retroperitoneum (the kidneys, the aorta, abdominal lymph nodes
* the appendix
Types of incisions
Midline
The most common incision for laparotomy is the midline incision, a vertical incision which follows the linea alba.
* The upper midline incision usually extends from the xiphoid process to the umbilicus.
* A typical lower midline incision is limited by the umbilicus superiorly and by the pubic symphysis inferiorly.
* Sometimes a single incision extending from xiphoid process to pubic symphysis is employed, especially in trauma surgery.
Midline incisions are particularly favoured in diagnostic laparotomy, as they allow wide access to most of the abdominal cavity.
Other
Other common laparotomy incisions include:
* the Kocher (right subcostal) incision (after Emil Theodor Kocher); appropriate for certain operations on the liver, gallbladder and biliary tract;[1][2]
* the Davis or Rockey-Davis "muscle-splitting" right lower quadrant incision for appendectomy;
* the Pfannenstiel incision, a transverse incision below the umbilicus and just above the pubic symphysis.[3][4] In the classic Pfannenstiel incision, the skin and subcutaneous tissue are incised transversally, but the linea alba is opened vertically. It is the incision of choice for Cesarean section and for abdominal hysterectomy for benign disease. A variation of this incision is the Maylard incision in which the rectus abdominis muscles are sectioned transversally to permit wider access to the pelvis.[5]
* Lumbotomy consists of a lumbar incision which permits access to the kidneys (which are retroperitoneal) without entering the peritoneal cavity. It is typically used only for benign renal lesions. It has also been proposed for surgery of the upper urological tract.[6]
Related procedures
A related procedure is laparoscopy, where cameras and other instruments are inserted into the peritoneal cavity via small holes in the abdomen. For example, an appendectomy can be done either by a laparotomy or by a laparoscopic approach.
VIDEO
NEXT UP
Reduction Mammoplasty
Laparotomy
A laparotomy is a surgical procedure involving an incision through the abdominal wall to gain access into the abdominal cavity. It is also known as coeliotomy.
Terminology
In diagnostic laparotomy (most often referred to as an exploratory laparotomy and abbreviated Ex-Lap), the nature of the disease is unknown, and laparotomy is deemed the best way to identify the cause.
In therapeutic laparotomy, a cause has been identified (e.g. peptic ulcer, colon cancer) and laparotomy is required for its therapy.
Usually, only exploratory laparotomy is referred to as a surgical operation by itself; and when a specific operation is already planned, laparotomy is considered merely the first step of the procedure.
Spaces accessed
Depending on incision placement, it may give access to any abdominal organ or space, and is the first step in any major diagnostic or therapeutic surgical procedure of these organs, which include:
* the lower part of the digestive tract (the stomach, duodenum, jejunum, ileum and colon)
* the liver, pancreas and spleen
* the bladder
* the female reproductive organs (the uterus and ovaries)
* the retroperitoneum (the kidneys, the aorta, abdominal lymph nodes
* the appendix
Types of incisions
Midline
The most common incision for laparotomy is the midline incision, a vertical incision which follows the linea alba.
* The upper midline incision usually extends from the xiphoid process to the umbilicus.
* A typical lower midline incision is limited by the umbilicus superiorly and by the pubic symphysis inferiorly.
* Sometimes a single incision extending from xiphoid process to pubic symphysis is employed, especially in trauma surgery.
Midline incisions are particularly favoured in diagnostic laparotomy, as they allow wide access to most of the abdominal cavity.
Other
Other common laparotomy incisions include:
* the Kocher (right subcostal) incision (after Emil Theodor Kocher); appropriate for certain operations on the liver, gallbladder and biliary tract;[1][2]
* the Davis or Rockey-Davis "muscle-splitting" right lower quadrant incision for appendectomy;
* the Pfannenstiel incision, a transverse incision below the umbilicus and just above the pubic symphysis.[3][4] In the classic Pfannenstiel incision, the skin and subcutaneous tissue are incised transversally, but the linea alba is opened vertically. It is the incision of choice for Cesarean section and for abdominal hysterectomy for benign disease. A variation of this incision is the Maylard incision in which the rectus abdominis muscles are sectioned transversally to permit wider access to the pelvis.[5]
* Lumbotomy consists of a lumbar incision which permits access to the kidneys (which are retroperitoneal) without entering the peritoneal cavity. It is typically used only for benign renal lesions. It has also been proposed for surgery of the upper urological tract.[6]
Related procedures
A related procedure is laparoscopy, where cameras and other instruments are inserted into the peritoneal cavity via small holes in the abdomen. For example, an appendectomy can be done either by a laparotomy or by a laparoscopic approach.
VIDEO
NEXT UP
Reduction Mammoplasty
Tuesday, May 26, 2009
Sigmoidoscopy
PROCEDURE OF THE DAY
Sigmoidoscopy
Sigmoidoscopy is the minimally invasive medical examination of the large intestine from the rectum through the last part of the colon. There are two types of sigmoidoscopy, flexible sigmoidoscopy, which uses a flexible endoscope, and rigid sigmoidoscopy, which uses a rigid device. Flexible sigmoidoscopy is generally the preferred procedure. A sigmoidoscopy is a very effective screening tool. A sigmoidoscopy is similar but not the same as a colonoscopy. A Sigmoidoscopy only examines up to the sigmoid, the most distal part of the colon, while colonoscopy examines the whole large bowel.
Flexible sigmoidoscopy
Flexible sigmoidoscopy enables the physician to look at the inside of the large intestine from the rectum through the last part of the colon, called the sigmoid. Physicians may use the procedure to find the cause of diarrhea, abdominal pain, or constipation. They also use it to look for benign and malignant polyps, as well as early signs of cancer in the descending colon and rectum. With flexible sigmoidoscopy, the physician can see intestinal bleeding, inflammation, abnormal growths, and ulcers in the descending colon and rectum. Flexible sigmoidoscopy is not sufficient to detect polyps or cancer in the ascending or transverse colon (two-thirds of the colon). However, although in absolute terms only a relatively small section of the large intestine can be examined using sigmoidoscopy, the sites which can be observed represent areas which are affected by diseases such as colorectal cancer most regularly, eg. the rectum.
For the procedure, the patient must lie on his or her left side on the examining table. The physician inserts a short, flexible, lit tube into the rectum and slowly guides it into the colon. The tube is called a sigmoidoscope. The scope transmits an image of the inside of the rectum and colon, so the physician can carefully examine the lining of these organs. The scope also blows air into these organs, which inflates them and helps the physician see better.
If anything unusual is in the rectum or colon, like a polyp or inflamed tissue, the physician can remove a piece of it using instruments inserted into the scope. The physician will send that piece of tissue (biopsy) to the lab for testing.
Bleeding and puncture of the colon are possible complications of sigmoidoscopy. However, such complications are uncommon.
Flexible sigmoidoscopy takes 10 to 20 minutes. During the procedure, the patient might feel pressure and slight cramping in the lower abdomen, but he or she will feel better afterward when the air leaves the colon.
Preparation
The colon and rectum must be completely empty for flexible sigmoidoscopy to be thorough and safe, so the physician will probably tell the patient to drink only clear liquids for 12 to 24 hours beforehand. A liquid diet means fat-free bouillon or broth, gelatin, strained fruit juice, water, plain coffee, plain tea, or diet soft drinks. The night before or right before the procedure, the patient receives a laxative and an enema, which is a liquid solution that washes out the intestines.
No sedation is required during this procedure as long as the examination does not exceed the level of the splenic flexure.
Rigid sigmoidoscopy
Rigid sigmoidoscopy no longer has the value it had in the past, before the advent of videocolonoscopy (flexible sigmoidoscopy). However, it may be still useful in ano-rectal diseases such as bleeding per rectum or inflammatory rectal disease, particularly in the general practice and pediatrics.
For performing the examination, the patient must lie on the left side, in the so called Sim's position. The bowels are previously emptied with a suppository and a digital rectal examination is first performed. The sigmoidoscope is lubricated and inserted with obturator in general direction of the navel. The direction is then changed and the obturaror is removed so that the physician may penetrate further with direct vision. A bellows is used to insufflate air to distend the rectum. Lateral movements of the sigmoidoscope's tip negotiate the Houston valve and the recto-sigmoid junction.
Risks
Although generally considered quite safe, sigmoidoscopy does carry the very rare possibility of tearing of the intestinal wall by the instrument, which would require immediate major surgery to repair the tear; in addition, removal of a polyp may sometimes lead to localized bleeding which is resistant to cauterization by the instrument and must be stopped by surgical intervention.
VIDEO
NEXT UP
Laparotomy
Sigmoidoscopy
Sigmoidoscopy is the minimally invasive medical examination of the large intestine from the rectum through the last part of the colon. There are two types of sigmoidoscopy, flexible sigmoidoscopy, which uses a flexible endoscope, and rigid sigmoidoscopy, which uses a rigid device. Flexible sigmoidoscopy is generally the preferred procedure. A sigmoidoscopy is a very effective screening tool. A sigmoidoscopy is similar but not the same as a colonoscopy. A Sigmoidoscopy only examines up to the sigmoid, the most distal part of the colon, while colonoscopy examines the whole large bowel.
Flexible sigmoidoscopy
Flexible sigmoidoscopy enables the physician to look at the inside of the large intestine from the rectum through the last part of the colon, called the sigmoid. Physicians may use the procedure to find the cause of diarrhea, abdominal pain, or constipation. They also use it to look for benign and malignant polyps, as well as early signs of cancer in the descending colon and rectum. With flexible sigmoidoscopy, the physician can see intestinal bleeding, inflammation, abnormal growths, and ulcers in the descending colon and rectum. Flexible sigmoidoscopy is not sufficient to detect polyps or cancer in the ascending or transverse colon (two-thirds of the colon). However, although in absolute terms only a relatively small section of the large intestine can be examined using sigmoidoscopy, the sites which can be observed represent areas which are affected by diseases such as colorectal cancer most regularly, eg. the rectum.
For the procedure, the patient must lie on his or her left side on the examining table. The physician inserts a short, flexible, lit tube into the rectum and slowly guides it into the colon. The tube is called a sigmoidoscope. The scope transmits an image of the inside of the rectum and colon, so the physician can carefully examine the lining of these organs. The scope also blows air into these organs, which inflates them and helps the physician see better.
If anything unusual is in the rectum or colon, like a polyp or inflamed tissue, the physician can remove a piece of it using instruments inserted into the scope. The physician will send that piece of tissue (biopsy) to the lab for testing.
Bleeding and puncture of the colon are possible complications of sigmoidoscopy. However, such complications are uncommon.
Flexible sigmoidoscopy takes 10 to 20 minutes. During the procedure, the patient might feel pressure and slight cramping in the lower abdomen, but he or she will feel better afterward when the air leaves the colon.
Preparation
The colon and rectum must be completely empty for flexible sigmoidoscopy to be thorough and safe, so the physician will probably tell the patient to drink only clear liquids for 12 to 24 hours beforehand. A liquid diet means fat-free bouillon or broth, gelatin, strained fruit juice, water, plain coffee, plain tea, or diet soft drinks. The night before or right before the procedure, the patient receives a laxative and an enema, which is a liquid solution that washes out the intestines.
No sedation is required during this procedure as long as the examination does not exceed the level of the splenic flexure.
Rigid sigmoidoscopy
Rigid sigmoidoscopy no longer has the value it had in the past, before the advent of videocolonoscopy (flexible sigmoidoscopy). However, it may be still useful in ano-rectal diseases such as bleeding per rectum or inflammatory rectal disease, particularly in the general practice and pediatrics.
For performing the examination, the patient must lie on the left side, in the so called Sim's position. The bowels are previously emptied with a suppository and a digital rectal examination is first performed. The sigmoidoscope is lubricated and inserted with obturator in general direction of the navel. The direction is then changed and the obturaror is removed so that the physician may penetrate further with direct vision. A bellows is used to insufflate air to distend the rectum. Lateral movements of the sigmoidoscope's tip negotiate the Houston valve and the recto-sigmoid junction.
Risks
Although generally considered quite safe, sigmoidoscopy does carry the very rare possibility of tearing of the intestinal wall by the instrument, which would require immediate major surgery to repair the tear; in addition, removal of a polyp may sometimes lead to localized bleeding which is resistant to cauterization by the instrument and must be stopped by surgical intervention.
VIDEO
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Laparotomy
Monday, May 25, 2009
Hepatectomy
PROCEDURE OF THE DAY
Hepatectomy
Hepatectomy consists on the surgical resection of the liver. While the term is often employed for the removal of the liver from a liver transplant recipient, this article will focus on partial resections of hepatic tissue.
History
The first successful anatomic hepatectomy was reported by Jean-Louis Lortat-Jacob in 1952, the patient being a 58-year-old woman diagnosed with colorectal cancer which had metastasized to the liver.
Indications
Most hepatectomies are performed for the treatment of hepatic neoplasms, both benign or malignant.
Benign neoplasms include hepatocellular adenoma, hepatic hemangioma and focal nodular hyperplasia.
The most common malignant neoplasms (cancers) of the liver are metastases; those arising from colorectal cancer are among the most common, and the most amenable to surgical resection. The most common primary malignant tumour of the liver is the hepatocellular carcinoma.
Hepatectomy may also be the procedure of choice to treat intrahepatic gallstones or parasitic cysts of the liver.
Technique
Access is accomplished by laparotomy, typically by a bilateral subcostal ("chevron") incision, possibly with midline extension (Calne or "Mercedes-Benz" incision).
Hepatectomies may be anatomic, i.e. the lines of resection match the limits of one or more functional segments of the liver as defined by the Couinaud classification (cf. liver#Functional anatomy); or they may be non-anatomic, irregular or "wedge" hepatectomies.
Anatomic resections are generally preferred because of the smaller risk of bleeding and biliary fistula; however, non-anatomic resections can be performed safely as well in selected cases. For details on the variety of anatomic hepatectomies and the specific nomenclature, cf. the International Hepato-Pancreatico-Biliary Association (IHPBA) Terminology for Liver Resections
Complications
Bleeding is the most feared technical complication and may be grounds for urgent reoperation. Biliary fistula is also a possible complication, albeit one more amenable to nonsurgical management. Pulmonary complications such as atelectasis and pleural effusion are commonplace, and dangerous in patients with underlying lung disease. Infection is relatively rare.
Liver failure poses a significant hazard to patients with underlying hepatic disease; this is a major deterrent in the surgical resection of hepatocellular carcinoma in patients with cirrhosis. It is also a problem, to a lesser degree, in patients with previous hepatectomies (e.g. repeat resections for reincident colorectal cancer metastases).
Results
Liver surgery is safe when performed by experienced surgeons with appropriate technological and institutional support. As with most major surgical procedures, there is a marked tendency towards optimal results at the hands of surgeons with high caseloads in selected centres (typically cancer centres and transplantation centres).
For optimal results, combination treatment with systemic or regionally infused chemo or biological therapy should be considered. Prior to surgery, cytotoxic agents such as oxaliplatin given systemically for colorectal metastasis, or chemoembolization for hepatocellular carcinoma can significantly decrease the size of the tumor bulk, allowing then for resections which would remove a segment or wedge portion of the liver only. These procedures can also be aided by application of liver clamp (Lin or Chu liver clamp; Pilling no.604113-61995) in order to minimize blood loss.
VIDEO
NEXT UP
Sigmoidoscopy
Hepatectomy
Hepatectomy consists on the surgical resection of the liver. While the term is often employed for the removal of the liver from a liver transplant recipient, this article will focus on partial resections of hepatic tissue.
History
The first successful anatomic hepatectomy was reported by Jean-Louis Lortat-Jacob in 1952, the patient being a 58-year-old woman diagnosed with colorectal cancer which had metastasized to the liver.
Indications
Most hepatectomies are performed for the treatment of hepatic neoplasms, both benign or malignant.
Benign neoplasms include hepatocellular adenoma, hepatic hemangioma and focal nodular hyperplasia.
The most common malignant neoplasms (cancers) of the liver are metastases; those arising from colorectal cancer are among the most common, and the most amenable to surgical resection. The most common primary malignant tumour of the liver is the hepatocellular carcinoma.
Hepatectomy may also be the procedure of choice to treat intrahepatic gallstones or parasitic cysts of the liver.
Technique
Access is accomplished by laparotomy, typically by a bilateral subcostal ("chevron") incision, possibly with midline extension (Calne or "Mercedes-Benz" incision).
Hepatectomies may be anatomic, i.e. the lines of resection match the limits of one or more functional segments of the liver as defined by the Couinaud classification (cf. liver#Functional anatomy); or they may be non-anatomic, irregular or "wedge" hepatectomies.
Anatomic resections are generally preferred because of the smaller risk of bleeding and biliary fistula; however, non-anatomic resections can be performed safely as well in selected cases. For details on the variety of anatomic hepatectomies and the specific nomenclature, cf. the International Hepato-Pancreatico-Biliary Association (IHPBA) Terminology for Liver Resections
Complications
Bleeding is the most feared technical complication and may be grounds for urgent reoperation. Biliary fistula is also a possible complication, albeit one more amenable to nonsurgical management. Pulmonary complications such as atelectasis and pleural effusion are commonplace, and dangerous in patients with underlying lung disease. Infection is relatively rare.
Liver failure poses a significant hazard to patients with underlying hepatic disease; this is a major deterrent in the surgical resection of hepatocellular carcinoma in patients with cirrhosis. It is also a problem, to a lesser degree, in patients with previous hepatectomies (e.g. repeat resections for reincident colorectal cancer metastases).
Results
Liver surgery is safe when performed by experienced surgeons with appropriate technological and institutional support. As with most major surgical procedures, there is a marked tendency towards optimal results at the hands of surgeons with high caseloads in selected centres (typically cancer centres and transplantation centres).
For optimal results, combination treatment with systemic or regionally infused chemo or biological therapy should be considered. Prior to surgery, cytotoxic agents such as oxaliplatin given systemically for colorectal metastasis, or chemoembolization for hepatocellular carcinoma can significantly decrease the size of the tumor bulk, allowing then for resections which would remove a segment or wedge portion of the liver only. These procedures can also be aided by application of liver clamp (Lin or Chu liver clamp; Pilling no.604113-61995) in order to minimize blood loss.
VIDEO
NEXT UP
Sigmoidoscopy
Sunday, May 24, 2009
Percutaneous Endoscopic Gastrostomy
PROCEDURE OF THE DAY
Percutaneous Endoscopic Gastrostomy
A percutaneous endoscopic gastrostomy (PEG) is an endoscopic procedure for placing a tube into the stomach. It involves placing a tube into the stomach through the abdominal wall. It is an alternative to surgical gastrostomy. PEG tubes may also be extended into the small bowel. The procedure does not require a general anesthetic, although mild sedation is typically used.
The procedure is performed in order to place a gastric feeding tube as a long-term means of providing nutrition to patients who cannot productively take food orally. PEG administration of enteral feeds is the most commonly used method of nutritional support for patients in the community. Many stroke patients, for example, are at risk of aspiration pneumonia due to poor control over the swallowing muscles; some will benefit from a PEG performed to maintain nutrition. PEGs may also be inserted to decompress the stomach in cases of gastric volvulus.[1]
Indications
Gastrostomy may be indicated in numerous situations, usually those in which normal or nutrition (or nasogastric) feeding is impossible. The causes for these situations may be neurological (e.g. stroke), anatomical (e.g. cleft lip and palate during the process of correction) or other (e.g. radiation therapy for tumors in head & neck region).
In certain situations, the indication for PEG placement is more debatable. In advanced dementia, studies show that PEG placement does not in fact prolong life.[2] Indeed, work has been done to inform doctors and healthcare staff of the perceived futility of the treatment.[3]
A gastrostomy may also be placed to decompress the stomach contents in a patient with a malignant bowel obstruction. This is referred to as a "venting PEG" and is placed to prevent and manage nausea and vomiting.
A gastrostomy can also be used to treat volvulus of the stomach, where the stomach twists along one of its axes. The tube (or multiple tubes) is used for gastropexy, or adhering the stomach to the abdominal wall, preventing twisting of the stomach.[1]
Techniques
Two major techniques for placing PEGs have been described in the literature.
The Ponsky or Bard-Ponsky pull technique involves performing a gastroscopy to evaluate the anatomy of the stomach. The anterior stomach wall is identified and techniques are used to ensure that there is no organ between the wall and the skin:
* digital pressure is applied to the abdominal wall, which can be seen indenting the anterior gastric wall by the endoscopist.
* transillumination: the light emitted from the endoscope within the stomach can be seen through the abdominal wall.
* a small (21G, 40mm) needle is passed into the stomach before the larger cannula is passed.
An angiocath is used to puncture the abdominal wall through a small incision, and a soft guidewire is inserted through this and pulled out of the mouth. The feeding tube is attached to the guidewire and pulled through the mouth out of the incision.[4]
The Russell introducer technique involves a gastroscopy to evaluate the anatomy. The Seldinger technique is used to place a wire into the stomach, and a series of dilators are used to increase the size of the gastrostomy. The tube is then pushed in over the wire.[4]
Contraindications
As with the case of other types of feeding tubes, care must be made to place PEGs into an appropriate population. The following are contraindications to PEG use:[5]
Absolute contraindications
* Inability to perform an esophagogastroduodenoscopy
* Uncorrected coagulopathy
* Peritonitis
* Untreatable (loculated) massive ascites
* Bowel obstruction (unless the PEG is sited to provide drainage)
Relative contraindications
* Massive ascites
* Gastric mucosal abnormalities: large gastric varices, portal hypertensive gastropathy
* Previous abdominal surgery, including previous partial gastrectomy: increased risk of organs interposed between gastric wall and abdominal wall
* Morbid obesity: difficuties in locating stomach position by digital indentation of stomach and transillumination
* Gastric wall neoplasm
* Abdominal wall infection: increased risk of infection of PEG site
Complications
* Cellulitis (infection of the skin) around the gastrostomy site
* Haemorrhage
* Gastric ulcer either at the site of the button or on the opposite wall of the stomach ("kissing ulcer")
* Perforation of bowel (most commonly transverse colon) leading to peritonitis
* Puncture of the left lobe of the liver leading to liver capsule pain
* Gastrocolic fistula: this may be suspected if diarrhoea appears a short time after feeding. In this case, the feed goes direct from stomach to colon (usually transverse colon)
* Gastric separation
* "Buried bumper syndrome" (the gastric part of the tube migrates into the gastric wall)[6]
Removal of PEG tubes
Indications
* PEG tube no longer required (recovery of swallow after stroke or surgery for laryngeal cancer)
* Persistent infection of PEG site
* Failure, breakage or deterioration of PEG tube (a new tube can be sited along the existing track)
* "Buried bumper syndrome"
Techniques
PEG tubes with fixed "bumpers" are removed endoscopically. The PEG tube is pushed into the stomach so that part of the tube is visible behind the bumper. An endoscopy snare is then passed through the endoscope, and passed over the bumper so that the tube adjacent to the bumper is grasped. The external part of the tube is then cut, and the tube is withdrawn into the stomach, and then pulled up into the oesophagus and removed through the mouth. The PEG site heals without intervention.
PEG tubes with a deflatable bumper can be removed simply by pulling the PEG tube out through the abdominal wall once the bumper has been deflated (traction removable PEG tubes or "button" PEG tubes).
History
The first percutaneous endoscopic gastrostomies were performed at the Cleveland Clinic in children.
VIDEO
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Hepatectomy
Percutaneous Endoscopic Gastrostomy
A percutaneous endoscopic gastrostomy (PEG) is an endoscopic procedure for placing a tube into the stomach. It involves placing a tube into the stomach through the abdominal wall. It is an alternative to surgical gastrostomy. PEG tubes may also be extended into the small bowel. The procedure does not require a general anesthetic, although mild sedation is typically used.
The procedure is performed in order to place a gastric feeding tube as a long-term means of providing nutrition to patients who cannot productively take food orally. PEG administration of enteral feeds is the most commonly used method of nutritional support for patients in the community. Many stroke patients, for example, are at risk of aspiration pneumonia due to poor control over the swallowing muscles; some will benefit from a PEG performed to maintain nutrition. PEGs may also be inserted to decompress the stomach in cases of gastric volvulus.[1]
Indications
Gastrostomy may be indicated in numerous situations, usually those in which normal or nutrition (or nasogastric) feeding is impossible. The causes for these situations may be neurological (e.g. stroke), anatomical (e.g. cleft lip and palate during the process of correction) or other (e.g. radiation therapy for tumors in head & neck region).
In certain situations, the indication for PEG placement is more debatable. In advanced dementia, studies show that PEG placement does not in fact prolong life.[2] Indeed, work has been done to inform doctors and healthcare staff of the perceived futility of the treatment.[3]
A gastrostomy may also be placed to decompress the stomach contents in a patient with a malignant bowel obstruction. This is referred to as a "venting PEG" and is placed to prevent and manage nausea and vomiting.
A gastrostomy can also be used to treat volvulus of the stomach, where the stomach twists along one of its axes. The tube (or multiple tubes) is used for gastropexy, or adhering the stomach to the abdominal wall, preventing twisting of the stomach.[1]
Techniques
Two major techniques for placing PEGs have been described in the literature.
The Ponsky or Bard-Ponsky pull technique involves performing a gastroscopy to evaluate the anatomy of the stomach. The anterior stomach wall is identified and techniques are used to ensure that there is no organ between the wall and the skin:
* digital pressure is applied to the abdominal wall, which can be seen indenting the anterior gastric wall by the endoscopist.
* transillumination: the light emitted from the endoscope within the stomach can be seen through the abdominal wall.
* a small (21G, 40mm) needle is passed into the stomach before the larger cannula is passed.
An angiocath is used to puncture the abdominal wall through a small incision, and a soft guidewire is inserted through this and pulled out of the mouth. The feeding tube is attached to the guidewire and pulled through the mouth out of the incision.[4]
The Russell introducer technique involves a gastroscopy to evaluate the anatomy. The Seldinger technique is used to place a wire into the stomach, and a series of dilators are used to increase the size of the gastrostomy. The tube is then pushed in over the wire.[4]
Contraindications
As with the case of other types of feeding tubes, care must be made to place PEGs into an appropriate population. The following are contraindications to PEG use:[5]
Absolute contraindications
* Inability to perform an esophagogastroduodenoscopy
* Uncorrected coagulopathy
* Peritonitis
* Untreatable (loculated) massive ascites
* Bowel obstruction (unless the PEG is sited to provide drainage)
Relative contraindications
* Massive ascites
* Gastric mucosal abnormalities: large gastric varices, portal hypertensive gastropathy
* Previous abdominal surgery, including previous partial gastrectomy: increased risk of organs interposed between gastric wall and abdominal wall
* Morbid obesity: difficuties in locating stomach position by digital indentation of stomach and transillumination
* Gastric wall neoplasm
* Abdominal wall infection: increased risk of infection of PEG site
Complications
* Cellulitis (infection of the skin) around the gastrostomy site
* Haemorrhage
* Gastric ulcer either at the site of the button or on the opposite wall of the stomach ("kissing ulcer")
* Perforation of bowel (most commonly transverse colon) leading to peritonitis
* Puncture of the left lobe of the liver leading to liver capsule pain
* Gastrocolic fistula: this may be suspected if diarrhoea appears a short time after feeding. In this case, the feed goes direct from stomach to colon (usually transverse colon)
* Gastric separation
* "Buried bumper syndrome" (the gastric part of the tube migrates into the gastric wall)[6]
Removal of PEG tubes
Indications
* PEG tube no longer required (recovery of swallow after stroke or surgery for laryngeal cancer)
* Persistent infection of PEG site
* Failure, breakage or deterioration of PEG tube (a new tube can be sited along the existing track)
* "Buried bumper syndrome"
Techniques
PEG tubes with fixed "bumpers" are removed endoscopically. The PEG tube is pushed into the stomach so that part of the tube is visible behind the bumper. An endoscopy snare is then passed through the endoscope, and passed over the bumper so that the tube adjacent to the bumper is grasped. The external part of the tube is then cut, and the tube is withdrawn into the stomach, and then pulled up into the oesophagus and removed through the mouth. The PEG site heals without intervention.
PEG tubes with a deflatable bumper can be removed simply by pulling the PEG tube out through the abdominal wall once the bumper has been deflated (traction removable PEG tubes or "button" PEG tubes).
History
The first percutaneous endoscopic gastrostomies were performed at the Cleveland Clinic in children.
VIDEO
NEXT UP
Hepatectomy
Saturday, May 23, 2009
Hatmann's Procedure
PROCEDURE OF THE DAY
Hartmann's Procedure
Hartmann's operation is the surgical resection of the rectosigmoid colon with closure of the rectal stump and colostomy. It was used to treat colon cancer or diverticulitis. These days its use is limited to emergency surgery when immediate anastomosis is not possible, or more rarely it is used palliatively in colorectal tumours.[1] The procedure was first described by Henri Hartmann in 1921.[2] The procedure is described in detail in his book, Chirurgie du Rectum, which was published in 1931 and constituted volume 8 of his Travaux de Chirurgie.[3]
The Hartmann's procedure with a proximal-end colostomy or ileostomy is the most common operation carried out by general surgeons for management of malignant obstruction of the distal colon. During this procedure, the lesion is removed, the distal bowel closed intraperitoneally, and the proximal bowel diverted with a stoma.
The indications for this procedure include:
a. Localized or generalized peritonitis caused by perforation of the bowel secondary to the cancer
b. Viable but injured proximal bowel that, in the opinion of the operating surgeon, precludes safe anastomosis.
Use of the Hartmann's procedure has been associated with a low perioperative mortality of 9%, but at the cost of a colostomy that, in up to two-thirds of patients, is never reversed.
VIDEO
*None*
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Percutaneous Endoscopic Gastrostomy
Hartmann's Procedure
Hartmann's operation is the surgical resection of the rectosigmoid colon with closure of the rectal stump and colostomy. It was used to treat colon cancer or diverticulitis. These days its use is limited to emergency surgery when immediate anastomosis is not possible, or more rarely it is used palliatively in colorectal tumours.[1] The procedure was first described by Henri Hartmann in 1921.[2] The procedure is described in detail in his book, Chirurgie du Rectum, which was published in 1931 and constituted volume 8 of his Travaux de Chirurgie.[3]
The Hartmann's procedure with a proximal-end colostomy or ileostomy is the most common operation carried out by general surgeons for management of malignant obstruction of the distal colon. During this procedure, the lesion is removed, the distal bowel closed intraperitoneally, and the proximal bowel diverted with a stoma.
The indications for this procedure include:
a. Localized or generalized peritonitis caused by perforation of the bowel secondary to the cancer
b. Viable but injured proximal bowel that, in the opinion of the operating surgeon, precludes safe anastomosis.
Use of the Hartmann's procedure has been associated with a low perioperative mortality of 9%, but at the cost of a colostomy that, in up to two-thirds of patients, is never reversed.
VIDEO
*None*
NEXT UP
Percutaneous Endoscopic Gastrostomy
Friday, May 22, 2009
Minimaze Procedure
PROCEDURE OF THE DAY
Minimaze Procedure
The mini-maze procedures are cardiac surgery procedures intended to cure atrial fibrillation (AF), a common disturbance of heart rhythm. They are procedures derived from the original maze procedure developed by James Cox, MD. Recently, various methods of minimally invasive maze procedures have been developed; these procedures are collectively named minimaze - "mini" versions of the original maze surgery.
The origin of the mini-maze procedures: The Cox maze procedure
James Cox, MD, and associates developed the "maze" or "Cox maze" procedure, an "open-heart" cardiac surgery procedure intended to eliminate atrial fibrillation, and performed the first one in 1987.[1] “Maze” refers to the series of incisions arranged in a maze-like pattern in the atria. The intention was to eliminate AF by using incisional scars to block abnormal electrical circuits (atrial macroreentry) that AF requires. This required an extensive series of endocardial (from the inside of the heart) incisions through both atria, a median sternotomy (vertical incision through the breastbone) and cardiopulmonary bypass (heart-lung machine; extracorporeal circulation). A series of improvements were made, culminating in 1992 in the Cox maze III procedure, which is now considered to be the "gold standard” for effective surgical cure of AF. It was quite successful in eliminating AF, but had drawbacks as well.[2] The Cox maze III is sometimes referred to as the “Traditional maze”, the “cut and sew maze”, or simply the "maze".
Minimally invasive epicardial surgical procedures for AF (minimaze)
Efforts have since been made to equal the success of the Cox maze III while reducing surgical complexity and likelihood of complications. During the late 1990s, operations similar to the Cox maze, but with fewer atrial incisions, led to the use of the terms "minimaze", "mini maze" and “mini-maze”,[3] although these were still major operations.
A primary goal has been to perform a curative, "maze-like" procedure epicardially (from the outside of the heart), so that it could be performed on a normally beating heart, without cardiopulmonary bypass. Until recently this was not thought possible; as recently as 2004, Dr. Cox defined the mini-maze as requiring an endocardial approach:
“In summary, it would appear that placing the following lesions can cure most patients with atrial fibrillation of either type: pulmonary vein encircling incision, left atrial isthmus lesion with its attendant coronary sinus lesion, and the right atrial isthmus lesion. We call this pattern of atrial lesions the “mini-maze Procedure” ... None of the present energy sources—including cryotherapy, unipolar radiofrequency, irrigated radiofrequency, bipolar radiofrequency, microwave, and laser energy—are capable of creating the left atrial isthmus lesion from the epicardial surface, because of the necessity of penetrating through the circumflex coronary artery to reach the left atrial wall near the posterior mitral annulus. Therefore, the mini-maze procedure cannot be performed epicardially by means of any presently available energy source.”[4]
Although Dr. Cox's 2004 definition specifically excludes an epicardial approach to eliminate AF, he and others pursued this important goal, and the meaning of the term changed as successful epicardial procedures were developed. In 2002 Saltman performed a completely endoscopic surgical ablation of AF[5] and subsequently published their results in 14 patients.[6] These were performed epicardially, on the beating heart, without cardiopulmonary bypass or median sternotomy. Their method came to be known as the minimaze or microwave minimaze procedure, because microwave energy was used to make the lesions that had previously been performed by the surgeon's scalpel.
Shortly thereafter, Randall K. Wolf, MD and others developed a procedure using radiofrequency energy rather than microwave, and different, slightly larger incisions. In 2005, he published his results in the first 27 patients.[7] This came to be known as the Wolf minimaze procedure.
Today, the terms “minimaze”, "mini-maze", and "mini maze" are still sometimes used to describe open heart procedures requiring cardiopulmonary bypass and median sternotomy, but are more commonly they refer to minimally invasive, epicardial procedures not requiring cardiopulmonary bypass, such as those developed by Saltman, Wolf, and others. These procedures are characterized by:
1. No median sternotomy incision; instead, an endoscope and/or “mini-thoracotomy” incisions between the ribs are used.
2. No cardiopulmonary bypass; instead, these procedures are performed on the normally beating heart.
3. Few or no actual incisions into the heart itself. The "maze" lesions are made epicardially by using radiofrequency, microwave, or ultrasonic energy, or by cryosurgery.
4. The part of the left atrium in which most clots form (the “appendage”) is usually removed, in an effort to reduce the long-term likelihood of stroke.
Microwave minimaze
Completely Endoscopic Microwave Ablation of Atrial Fibrillation on the Beating Heart Using Bilateral Thoracoscopy: The microwave minimaze requires three 5 mm to 1cm incisions on each side of the chest for the surgical tools and the endoscope. The pericardium is entered, and two sterile rubber tubes are threaded behind the heart, in the transverse and oblique sinuses. These tubes are joined together, then used to guide the flexible microwave antenna energy source through the sinuses behind the heart, to position it for ablation. Energy is delivered and the atrial tissue heated and destroyed in a series of steps as the microwave antenna is withdrawn behind the heart. The lesions form a "box-like" pattern around all four pulmonary veins behind the heart. The left atrial appendage is usually removed.[5][6] A very thorough description of the procedure is available.
Wolf minimaze
Video-assisted Bilateral Epicardial Bipolar Radiofrequency Pulmonary Vein Isolation and Left Atrial Appendage Excision: The Wolf minimaze requires one 5cm and two 1cm incisions on each side of the chest. These incisions allow the surgeon to maneuver the tools, view areas through an endoscope, and to see the heart directly. The right side of the left atrium is exposed first. A clamp-like tool is positioned on the left atrium near the right pulmonary veins, and the atrial tissue is heated between the jaws of the clamp, cauterizing the area. The clamp is removed. The autonomic nerves (ganglionated plexi) that may cause AF[8] may be eliminated as well. Subsequently the left side of the chest is entered. The ligament of Marshall (a vestigial structure with marked autonomic activity) is removed. The clamp is subsequently positioned on the left atrium near the left pulmonary veins for ablation. Direct testing to demonstrate complete electrical isolation of the pulmonary veins, and that the ganglionated plexi are no longer active, may be performed.[7]
High Intensity Focused Ultrasound (HIFU) minimaze
Surgical ablation of atrial fibrillation with off-pump, epicardial, high-intensity focused ultrasound: Although the HIFU minimaze is performed epicardially, on the normally beating heart, it is also usually performed in conjunction with other cardiac surgery, and so would not be minimally invasive in those cases. An ultrasonic device is positioned epicardially, on the left atrium, around the pulmonary veins, and intense acoustic energy is directed at the atrium to destroy tissue in the appropriate regions near the pulmonary veins.[9]
Mechanism of Elimination of Atrial Fibrillation
The mechanism by which AF is eliminated by curative procedures such as the maze, minimaze, or catheter ablation is controversial. All successful methods destroy tissue in the areas of the left atrium near the junction of the pulmonary veins, hence these regions are thought to be important. A concept gaining support is that paroxysmal AF is mediated in part by the autonomic nervous system [8] and that the intrinsic cardiac nervous system, which is located in these regions, plays an important role.[10] Supporting this is the finding that targeting these autonomic sites improves the likelihood of successful elimination of AF by catheter ablation.[11][12]
Patient Selection
The minimaze procedures are alternatives to catheter ablation of AF, and the patient selection criteria are similar. Patients are considered for minimaze procedures if they have moderate or severe symptoms and have failed medical therapy; asymptomatic patients are generally not considered. Those most likely to have a good outcome have paroxysmal (intermittent) AF, and have a heart that is relatively normal. Those with severely enlarged atria, marked cardiomyopathy, or severely leaking heart valves are less likely to have a successful result; these procedures are generally not recommended for such patients. Previous cardiac surgery provides technical challenges due to scarring on the outside of the heart, but does not always preclude minimaze surgery.
Surgical Results
Long-term success of the minimaze procedures awaits a consensus. Attaining a consensus is hindered by several problems; perhaps the most important of these is incomplete or inconsistent post-procedure follow-up to determine if atrial fibrillation has recurred, although many reasons have been considered.[13] It has been clearly demonstrated that longer or more intensive follow-up identifies much more recurrent atrial fibrillation,[14] hence a procedure with more careful follow-up will appear to be less successful. In addition, procedures continue to evolve rapidly, so long follow-up data do not accurately reflect current procedural methods. For more recent minimaze procedures, only relatively small and preliminary reports are available. With those caveats in mind, it can be said that reported short-term freedom from atrial fibrillation following the radiofrequency ("Wolf") procedure ranges from 67% to 91% [6][7][9] with longer-term results in a similar range, but limited primarily to patients with paroxysmal atrial fibrillation.
VIDEO
NEXT UP
Hartmann's Operation
Minimaze Procedure
The mini-maze procedures are cardiac surgery procedures intended to cure atrial fibrillation (AF), a common disturbance of heart rhythm. They are procedures derived from the original maze procedure developed by James Cox, MD. Recently, various methods of minimally invasive maze procedures have been developed; these procedures are collectively named minimaze - "mini" versions of the original maze surgery.
The origin of the mini-maze procedures: The Cox maze procedure
James Cox, MD, and associates developed the "maze" or "Cox maze" procedure, an "open-heart" cardiac surgery procedure intended to eliminate atrial fibrillation, and performed the first one in 1987.[1] “Maze” refers to the series of incisions arranged in a maze-like pattern in the atria. The intention was to eliminate AF by using incisional scars to block abnormal electrical circuits (atrial macroreentry) that AF requires. This required an extensive series of endocardial (from the inside of the heart) incisions through both atria, a median sternotomy (vertical incision through the breastbone) and cardiopulmonary bypass (heart-lung machine; extracorporeal circulation). A series of improvements were made, culminating in 1992 in the Cox maze III procedure, which is now considered to be the "gold standard” for effective surgical cure of AF. It was quite successful in eliminating AF, but had drawbacks as well.[2] The Cox maze III is sometimes referred to as the “Traditional maze”, the “cut and sew maze”, or simply the "maze".
Minimally invasive epicardial surgical procedures for AF (minimaze)
Efforts have since been made to equal the success of the Cox maze III while reducing surgical complexity and likelihood of complications. During the late 1990s, operations similar to the Cox maze, but with fewer atrial incisions, led to the use of the terms "minimaze", "mini maze" and “mini-maze”,[3] although these were still major operations.
A primary goal has been to perform a curative, "maze-like" procedure epicardially (from the outside of the heart), so that it could be performed on a normally beating heart, without cardiopulmonary bypass. Until recently this was not thought possible; as recently as 2004, Dr. Cox defined the mini-maze as requiring an endocardial approach:
“In summary, it would appear that placing the following lesions can cure most patients with atrial fibrillation of either type: pulmonary vein encircling incision, left atrial isthmus lesion with its attendant coronary sinus lesion, and the right atrial isthmus lesion. We call this pattern of atrial lesions the “mini-maze Procedure” ... None of the present energy sources—including cryotherapy, unipolar radiofrequency, irrigated radiofrequency, bipolar radiofrequency, microwave, and laser energy—are capable of creating the left atrial isthmus lesion from the epicardial surface, because of the necessity of penetrating through the circumflex coronary artery to reach the left atrial wall near the posterior mitral annulus. Therefore, the mini-maze procedure cannot be performed epicardially by means of any presently available energy source.”[4]
Although Dr. Cox's 2004 definition specifically excludes an epicardial approach to eliminate AF, he and others pursued this important goal, and the meaning of the term changed as successful epicardial procedures were developed. In 2002 Saltman performed a completely endoscopic surgical ablation of AF[5] and subsequently published their results in 14 patients.[6] These were performed epicardially, on the beating heart, without cardiopulmonary bypass or median sternotomy. Their method came to be known as the minimaze or microwave minimaze procedure, because microwave energy was used to make the lesions that had previously been performed by the surgeon's scalpel.
Shortly thereafter, Randall K. Wolf, MD and others developed a procedure using radiofrequency energy rather than microwave, and different, slightly larger incisions. In 2005, he published his results in the first 27 patients.[7] This came to be known as the Wolf minimaze procedure.
Today, the terms “minimaze”, "mini-maze", and "mini maze" are still sometimes used to describe open heart procedures requiring cardiopulmonary bypass and median sternotomy, but are more commonly they refer to minimally invasive, epicardial procedures not requiring cardiopulmonary bypass, such as those developed by Saltman, Wolf, and others. These procedures are characterized by:
1. No median sternotomy incision; instead, an endoscope and/or “mini-thoracotomy” incisions between the ribs are used.
2. No cardiopulmonary bypass; instead, these procedures are performed on the normally beating heart.
3. Few or no actual incisions into the heart itself. The "maze" lesions are made epicardially by using radiofrequency, microwave, or ultrasonic energy, or by cryosurgery.
4. The part of the left atrium in which most clots form (the “appendage”) is usually removed, in an effort to reduce the long-term likelihood of stroke.
Microwave minimaze
Completely Endoscopic Microwave Ablation of Atrial Fibrillation on the Beating Heart Using Bilateral Thoracoscopy: The microwave minimaze requires three 5 mm to 1cm incisions on each side of the chest for the surgical tools and the endoscope. The pericardium is entered, and two sterile rubber tubes are threaded behind the heart, in the transverse and oblique sinuses. These tubes are joined together, then used to guide the flexible microwave antenna energy source through the sinuses behind the heart, to position it for ablation. Energy is delivered and the atrial tissue heated and destroyed in a series of steps as the microwave antenna is withdrawn behind the heart. The lesions form a "box-like" pattern around all four pulmonary veins behind the heart. The left atrial appendage is usually removed.[5][6] A very thorough description of the procedure is available.
Wolf minimaze
Video-assisted Bilateral Epicardial Bipolar Radiofrequency Pulmonary Vein Isolation and Left Atrial Appendage Excision: The Wolf minimaze requires one 5cm and two 1cm incisions on each side of the chest. These incisions allow the surgeon to maneuver the tools, view areas through an endoscope, and to see the heart directly. The right side of the left atrium is exposed first. A clamp-like tool is positioned on the left atrium near the right pulmonary veins, and the atrial tissue is heated between the jaws of the clamp, cauterizing the area. The clamp is removed. The autonomic nerves (ganglionated plexi) that may cause AF[8] may be eliminated as well. Subsequently the left side of the chest is entered. The ligament of Marshall (a vestigial structure with marked autonomic activity) is removed. The clamp is subsequently positioned on the left atrium near the left pulmonary veins for ablation. Direct testing to demonstrate complete electrical isolation of the pulmonary veins, and that the ganglionated plexi are no longer active, may be performed.[7]
High Intensity Focused Ultrasound (HIFU) minimaze
Surgical ablation of atrial fibrillation with off-pump, epicardial, high-intensity focused ultrasound: Although the HIFU minimaze is performed epicardially, on the normally beating heart, it is also usually performed in conjunction with other cardiac surgery, and so would not be minimally invasive in those cases. An ultrasonic device is positioned epicardially, on the left atrium, around the pulmonary veins, and intense acoustic energy is directed at the atrium to destroy tissue in the appropriate regions near the pulmonary veins.[9]
Mechanism of Elimination of Atrial Fibrillation
The mechanism by which AF is eliminated by curative procedures such as the maze, minimaze, or catheter ablation is controversial. All successful methods destroy tissue in the areas of the left atrium near the junction of the pulmonary veins, hence these regions are thought to be important. A concept gaining support is that paroxysmal AF is mediated in part by the autonomic nervous system [8] and that the intrinsic cardiac nervous system, which is located in these regions, plays an important role.[10] Supporting this is the finding that targeting these autonomic sites improves the likelihood of successful elimination of AF by catheter ablation.[11][12]
Patient Selection
The minimaze procedures are alternatives to catheter ablation of AF, and the patient selection criteria are similar. Patients are considered for minimaze procedures if they have moderate or severe symptoms and have failed medical therapy; asymptomatic patients are generally not considered. Those most likely to have a good outcome have paroxysmal (intermittent) AF, and have a heart that is relatively normal. Those with severely enlarged atria, marked cardiomyopathy, or severely leaking heart valves are less likely to have a successful result; these procedures are generally not recommended for such patients. Previous cardiac surgery provides technical challenges due to scarring on the outside of the heart, but does not always preclude minimaze surgery.
Surgical Results
Long-term success of the minimaze procedures awaits a consensus. Attaining a consensus is hindered by several problems; perhaps the most important of these is incomplete or inconsistent post-procedure follow-up to determine if atrial fibrillation has recurred, although many reasons have been considered.[13] It has been clearly demonstrated that longer or more intensive follow-up identifies much more recurrent atrial fibrillation,[14] hence a procedure with more careful follow-up will appear to be less successful. In addition, procedures continue to evolve rapidly, so long follow-up data do not accurately reflect current procedural methods. For more recent minimaze procedures, only relatively small and preliminary reports are available. With those caveats in mind, it can be said that reported short-term freedom from atrial fibrillation following the radiofrequency ("Wolf") procedure ranges from 67% to 91% [6][7][9] with longer-term results in a similar range, but limited primarily to patients with paroxysmal atrial fibrillation.
VIDEO
NEXT UP
Hartmann's Operation
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