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This improves the A nerve hook is then used to generate a plane between the surgical efciency and provides a more certain removal of inner dural layer and the tumor/pituitary gland surface generic 0.5 mg repaglinide with amex diabetes symptoms during exercise. The operative microscope can be adjusted to partially Closure visualize the medial wall of the cavernous sinus bilaterally purchase 2 mg repaglinide mastercard diabetes symptoms night sweats. In the presence of a small hole in the be delivered into the surgical feld via either injection of diaphragm sellae buy 2 mg repaglinide diabetes symptoms but normal blood sugar, the sella is packed with an abdominal fat 10 mL of air or saline through a lumbar drain buy discount repaglinide 2mg online diabetes diet lentils, by a Valsalva graft. The sella is then reconstructed with either the bony maneuver, or by jugular vein compression. How- autologous bone or cartilage is unavailable, a bioabsorbable 22 Microscopic versus Endoscopic Transsphenoidal Pituitary Surgery 233 plate must be used to reconstruct the anterior sellar wall. The primary ported the results of 219 female patients who underwent mi- diference is that after an endoscopic technique the defect is crosurgical resection of prolactinomas. Not only is the bony anterior sphenoidotomy larger patients treated between 1976 and 1979 and those treated in all directions, unlike the microscopic transseptal ap- between 1998 and 1992 to assess the role of surgery before proach, but also the nasal mucosa overlying the sphenoid (group 1) and during (group 2) the era of dopamine agonist is completely removed during the approach. Also because a speculum is not used, the adenomas and between 80 and 88% of patients with either fat graft can be more difcult to place during an endoscopic intrasellar or suprasellar macroadenomas displayed initial approach. The authors reported a 82% continued remission rate with a median follow-up I Microscopic Versus Endoscopic Surgical of 15. With regard to Cushing’s disease, Pouratian et al31 re- The microscopic transsphenoidal approach has been the most common technique for resecting pituitary lesions ported the outcomes in 111 patients with the diagnosis of over the past 40 years. Consequently, the majority of large Cushing’s disease without postoperative pathologic con- surgical series include patients with tumors primarily re- frmation. In addition, many of the older se- a drop in serum cortisol levels to 2 µg/mL or lower within ries do not diferentiate among those patients treated via 72 hours of surgery. The authors reported that 50% of the microscopic, endoscopic-assisted, or pure endoscopic patients achieved postoperative remission as compared approach. Over the past 10 years, larger case series have with 79% for the 490 total transsphenoidal operations been published reporting the surgical results using the pure for Cushing’s disease performed by this chapter’s senior endoscopic approach alone. Of the specimens, 161 contained tumor Microscopic Approach cell invasion and 192 displayed no evidence of invasion. In Laws and Jane21 reported their series of 4020 transsphe- addition, 291 specimens were from primary transsphenoidal noidal operations in which the majority of cases used the resection and 55 specimens were from repeat transsphenoi- microscope approach alone. The neuropathologist identifed dural invasion nonfunctioning adenomas and preoperative visual loss, 87% in 41% of the former group and in 69% in the latter group. Requirements for remis- dural invasion was noted in 50% of nonsecretory tumors sion included normalization of insulin-like growth factor-1 and in 30 to 35% of the secretory tumors. Acromegalic symptoms were improved undergoing primary tumor resection as compared with pa- in 95% of patents with a 10-year recurrence risk of only 2%. Finally, the authors pared with traditional craniotomy approaches, the results reported a 76. In comparing the microscopic versus the endoscopic approach, epistaxis decreased from 1. Over the past 10 years, reports detail- Endoscopic Approach ing the surgical outcomes following the endoscopic resec- tion of pituitary adenomas have emerged. These reports In assessing any surgical lesion, the surgeon must always have subsequently allowed for a comparison between the consider what surgical approach can best be utilized to max- microscopic and endoscopic techniques. As reported by Ciric et al,39 the surgeon’s experi- tients treated via a pure endoscopic approach. The operative microscope is a standard part of also compared complication rates to the rates reported by many neurosurgical operations from spinal to intracranial Ciric et al,39 generated via a national survey evaluating sur- procedures. Consequently, most neurosurgeons are familiar geons using a transseptal-transsphenoidal approach. For with how to manipulate the microscope to obtain an ideal nonsecretory adenomas, complete surgical resection was three-dimensional view. In addition, the microscope can confrmed via postoperative magnetic resonance imaging easily be positioned such that the manipulation of surgi- in 93% of cases using the pure endoscopic approach and in cal instruments is not impeded. An improved uses a nasal speculum, potentially allowing for decreased initial remission rate for secretory tumors was also seen injury to the nasal mucosa. The the microscopic transseptal versus the pure endoscopic ap- feld of view is narrow, restricting the view of anatomical proach, nasal septal perforations decreased from 6. Thus, this approach relies Frank et al40 also reported similar surgical outcomes in on such adjuncts as intraoperative fuoroscopy to assist with comparing the pure endoscopic approach versus the micro- the approach to the sella turcica. They also compared their surgical results limits the surgical view by line of sight. With regard to tu- 22 Microscopic versus Endoscopic Transsphenoidal Pituitary Surgery 235 mor resection, the sellar foor and cavernous sinus walls are Second, the assistant driving the endoscope must be con- rarely fully visible. The optic chiasm is also rarely visible, stantly aware of the endoscope’s position so that it does not limiting direct confrmation that it is adequately decom- interfere with the surgical instruments and does not rotate, pressed. Finally, the transseptal microscopic approach typi- providing incorrect information regarding the anatomical cally requires postoperative nasal packing. Finally, and as a corollary to this second issue, Compared with the microscopic technique, the endo- the surgeon must maximize the exposure of the sella turcica scopic approach ofers unique advantages to the surgeon. Consequently, the binasal endoscopic sight, the endoscope provides a panoramic view to identify exposure is larger than the microscopic exposure. The endoscope allows for a superior view of the nasal anatomy for identifcation of the sphenoid sinus. Consequently, fuoroscopic guidance is not I Conclusion necessary for safely reaching the sphenoid ostia. Once in- side the sphenoid sinus, the limits of the sella turcica can be The transsphenoidal resection of pituitary lesions has a rich accurately determined via identifcation of such anatomical history that dates to the beginning of the 20th century. The landmarks as the carotid protuberance and the opticoca- surgical approach has continually evolved over this time pe- rotid recess. The contributors to this evolution have all based their chal sphenoid sinus in which image guidance is still helpful. These goals include With regard to tumor resection, the endoscope provides a maximizing surgical resection of the lesion while minimizing magnifed view of the tumor–gland interface. As the neurosurgeon gains experi- tion of this interface can potentially lead to improvement in ence with any modifcation to the surgical approach, compli- both the degree of tumor resection as well as preservation cations will continue to decrease as surgical outcomes equal of normal pituitary gland function. In addition, the 0- and and perhaps surpass those achieved by previous techniques. As neurosurgeons gain experience with the requires nasal packing, which has been shown to correlate latter technique, surgical outcomes can be more accurately with improved patient comfort and satisfaction. The contribution of Davide Although the endoscopic approach ofers many advan- Giordano (1864–1954) to pituitary surgery: the transglabellar-nasal tages, it also has disadvantages. Neurosurgery 1998;42:909–911, discussion 911–912 not familiar with the endoscope, and a steep learning curve 2. For the oto- tion of Harvey Cushing’s surgical approach to pituitary tumors from laryngologist, the endoscopic approach demands more time transsphenoidal to transfrontal.
Patients likely to develop right8 ventricular ischemia or those with disease of the right coronary artery might benefit from monitoring of leads V or V order repaglinide 2mg amex diabetes medications prices. These recommendations describe a series of26 standard tomographic views of the heart and great vessels that should be included in a complete intraoperative echocardiographic examination effective repaglinide 2 mg diabetes mellitus uptodate. Selection of Anesthetic There is no one “ideal” anesthetic for patients with coronary artery disease purchase repaglinide paypal diabetes type 1 treatment new. The choice of anesthetic should be based on known hemodynamic order repaglinide online gestational diabetes definition of acog, pharmacologic, and pharmacokinetic effects of each drug as they apply to the particular patient, the experience of the anesthesiologist, and the relative cost–benefit of each agent, and should depend primarily on the extent of pre- existing myocardial dysfunction. If drugs are titrated to the desired effect, 2681 cardiovascular changes are minimized in healthy, as well as in patients with severe myocardial depression to facilitate a safe anesthetic. Most patients with mild or even moderate dysfunction may benefit from some degree of myocardial depression, which leads to decreased oxygen demand, and may alleviate or at least reduce episodes of ischemia. The increased use of benzodiazepines and volatile agents has been associated with low incidence of awareness. Intraoperative clinical variables, such as29 inotropic requirements or transfusion for bleeding, should be considered in the timing of postoperative extubation after fast-track cardiac surgery. In30 general, the use of low-dose opioid based general anesthesia and time- directed protocols for fast-track interventions have similar risks of mortality and major postoperative complications to conventional (not fast-track) care, and appear to be safe in patients considered to be at low to moderate risk. The current practice is to supplement the opioid with benzodiazepines and volatile agents. The planned time of extubation is now one of the major factors determining the selection and dosage of opioid. The beneficial cardioprotective and anti-32 inflammatory effects of morphine have been reconsidered recently,33,34 bringing back into the foray the opioid that reinvigorated the practice of cardiac anesthesia. Volatile anesthetics protect the myocardium from ischemia and reperfusion injury and reduce myocardial infarct size. This beneficial effect has been36 2682 shown when volatile anesthetics are administered before a period of prolonged ischemia (“anesthetic preconditioning”) as well as during reperfusion (“anesthetic postconditioning”). However, it is difficult to37 ascertain whether these laboratory-proven benefits have contributed to improved myocardial protection in clinical practice. An anesthetic based38 primarily on volatile agents may cause systemic hypotension (whether induced by decreased contractility or vasodilation), which may compromise the oxygen supply and lack of postoperative analgesia. Instead, balanced techniques based on combinations of opioids and any of the volatile anesthetics are advantageous with minimal untoward effects. Isoflurane is a coronary vasodilator, as are the other volatile anesthetics (although to a lesser degree). Clinical studies using isoflurane to clinical rather than pharmacologic end points have not shown increased episodes of ischemia or a worsened outcome. Desflurane and sevoflurane have the fastest39 recovery of all volatile anesthetics. Desflurane has a rapid uptake and distribution, allowing it to be useful in cases in which hemodynamic changes mandate rapid changes in anesthetic depth. When compared with volatile anesthetics,44 propofol was associated with less favorable cardiac function, higher need for inotropic support, and elevated plasma troponins after cardiac surgery in elderly patients. The principal vasoactive drugs are nitrates, β-blockers, peripheral 2683 vasoconstrictors, and calcium entry blockers. Volatile anesthetics can also be used to control blood pressure and reduce contractility. Adverse effects include cyanide and thiocyanate toxicity, rebound hypertension, intracranial hypertension, blood coagulation abnormalities, increased pulmonary shunting, and hypothyroidism. Greater risk51 of cyanide toxicity exists in patients who are nutritionally deficient in cobalamine (vitamin B compounds) or in dietary substances containing12 sulfur. Treatment should consist of discontinuing infusion, administering 100% O , administering amyl2 nitrate (inhaler) or intravenous sodium nitrite and intravenous thiosulfate, except in those patients with abnormal renal function, for whom hydroxocobalamin is recommended. Circulating levels of thiocyanate increase when renal function is compromised, and central nervous system abnormalities result when thiocyanate levels reach 5 to 10 μg/dL. In most situations, the increase in coronary perfusion pressure more than offsets any increase in wall tension. Peripheral vasoconstriction is needed during episodes of systemic hypotension, especially those caused by reduced surgical stimulation or drug- induced vasodilation. Indications for β-blockers include treatment of sinus tachycardia not caused by light anesthesia or hypovolemia, prophylaxis of, and slowing the ventricular response to, supraventricular dysrhythmias, hyperdynamic states, and control of ventricular dysrhythmias. Propranolol is a nonselective β-blocker with an elimination half-life of 4 to 6 hours. Metoprolol is similar to propranolol but has the purported advantage of β -1 selectivity and is less likely to trigger bronchospasm in patients with reactive airway disease. Labetalol combines β-blocking properties with those of α- blockade and is useful in treating hyperdynamic and hypertensive situations. Esmolol is a short-acting β -blocker that is cardioselective, with a half-life of1 only 9. It is particularly useful in treating transient increases in heart rate owing to episodic sympathetic stimulation. Calcium Channel Blockers Calcium channel blockers depress contractility, reduce coronary and systemic vascular tone, decrease sinoatrial node firing rate, and impede atrioventricular conduction57,58 at a remarkably variable degree. The negative inotropic effect is greatest with verapamil and less with nifedipine, diltiazem, and nicardipine (in decreasing order). Verapamil is particularly useful in the treatment of supraventricular tachycardia for slowing the ventricular response in atrial fibrillation and/or flutter, but its myocardial depressant effects limit its usefulness. Calcium channel blockers have been found to have cardioprotective effects during reperfusion. Nicardipine in particular has coronary antispasmodic and vasodilatory effects more than systemic arterial vasodilatory effects. Magnesium has61 coronary arterial dilating properties, reduces the size of myocardial infarction in the setting of acute ischemia, and decreases mortality associated with infarction. In addition, it is an antiarrhythmic and minimizes myocardial62 2686 reperfusion injury. Compensatory mechanisms consist of chamber enlargement, myocardial hypertrophy, and variations in vascular tone and level of sympathetic activity. These mechanisms in turn induce secondary alterations, including altered ventricular compliance, development of myocardial ischemia, cardiac dysrhythmias, and progressive myocardial dysfunction. The patient presenting for valve repair or replacement may have pulmonary hypertension, significant ventricular dysfunction, and chronic arrhythmias. For a safe anesthetic, understanding the altered loading conditions, preserving the compensatory mechanisms, maintaining circulatory homeostasis, and anticipating problems that may arise during and after valve surgery are important. In this section, we briefly describe the pathophysiology, desirable hemodynamic profile, and other pertinent anesthetic considerations for each valvular lesion. What in the past was thought to be “degenerative” is a disease continuum, similar to atherosclerosis. Increased calcification eventually leads66 to cusp immobility and outflow obstruction. Contractility is preserved and ejection fraction is maintained at a normal range until late in the disease process (Fig. The ventricular filling pressure, as reflected by pulmonary capillary wedge pressure, may vary widely with only small changes in ventricular volume (reduced compliance).
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When the meshes were positioned as a bridge discount repaglinide american express diabetes insipidus sugar, the reported recurrence rate was >80% discount 0.5mg repaglinide mastercard diabetes prevention 6 eating. A study by Booth and colleague compared primary fascial closure with mesh reinforcement with the use of the mesh as a bridge and demonstrated a higher recurrence rate (56% versus 8% order repaglinide 2mg free shipping diabetes test vårdcentral, p < 0 buy repaglinide in united states online diabetes diet wiki. A randomized controlled trial compared the traditional bridged mesh repair (with both synthetic and biologic meshes) with the component separa- tion technique with biologic mesh reinforcement : the trial demonstrated that recurrences were lower with the component separation plus mesh reinforcement technique (13. Component separation plus reinforcement was also associated with a lower infection rate (0 versus 23% in the bridged group, p = 0. They showed a rate of complicated wound of 47%, and they demonstrated a recurrence rate of 31% after a mean fol- low-up of 21 months. Great limitations of the study were the utilization of different kinds of prostheses in different positions (inlay, onlay, etc. A meta-analysis of 2012 reported data with a comparison among different types of meshes : the recurrence rate was similar for cross-linked and non-cross- linked porcine dermis (10% versus 8%) but was signifcantly higher for allogenic human dermis (recurrence rate 20%). Among the complications, postoperative infection and seroma were the most com- mon with a weighted incidence of 16. The removal of the prosthesis was reported in 2% of the cases due to poor mesh incorporation in the majority of cases. Cross-linked porcine meshes result in similar recurrence rate (11% versus 10%) and lower infection rate (9% versus 18%) compared to non- cross- linked meshes. Short- term results as wound infection, prosthetic explantation, and enterocutaneous fstula were comparable in the two groups; biologic meshes were associated with a higher incidence of hernia at follow-up. A recent meta-analysis by Sharrock and colleagues investigated the management and closure of open abdomen in trauma patients . Among the included studies, the point estimate recurrence rate of ventral hernia after 1 year of biologic mesh position- ing was 51%. However, the authors highlighted the small number of included studies and their poor quality, suggesting great caution in interpreting this result. Biological materials in infected felds had a recurrent hernia rate of 30% compared with 7% of synthetic materials, but data were derived from a single study and do not justify the use of synthetic materials, especially as a bridge position after open abdomen. Available evidences are really weak: all the cited meta-analysis included espe- cially poor-quality retrospective case series. There is also a great heterogeneity among indications for mesh implantation, mesh position, and type of mesh. Actually there is no randomized trial comparing different types of meshes or the indication to mesh positioning. Moreover no good quality comparative studies dedicated on closure of open abdomen are available. Several randomized controlled trials are ongoing to assess the safety and long-term results of biological prosthesis in abdominal wall reconstruction even if none of them is dedicated exclusively to open abdomen [50–58]. Conclusion No defnitive evidence-based conclusions could be obtained right now from the literature, and no clear indications in specifc situations could be defned for the use of biological prosthesis in abdominal wall repair. Biological prostheses have been designed to perform as a valid option for abdominal wall repair minimizing mesh-related complications, especially in contaminated surgical felds. In manag- ing great abdominal wall defects, especially after open abdomen, biological pros- thesis are a fundamental part of the armamentarium of our surgical practice and remains “the only option” in some troublesome situations despite the lack of robust evidences. The need for consensus on the role of biologic mesh in abdomi- nal wall reconstruction is evident. Randomized trials are diffcult to conduct, 20 Biological Prosthesis for Abdominal Wall Reconstruction 253 especially in open abdomen, and so prospective studies or large registries are needed with uniform defnitions and inclusion. At the moment, the positioning of a biological prosthesis as a bridge to close the abdomen seems to be the best and most obvious solution to solve the acute problem, keeping in mind the possibility to hernia recurrence in long-term follow-up. Long-term complications associated with pros- thetic repair of incisional hernias. The open abdomen and temporary abdominal closure systems - historical evolution and systematic review. Prevention of adhesion to prosthetic mesh: comparison of different barriers using an incisional hernia model. Comparison of host response to polypropylene and non-cross-linked porcine small intestine serosal-derived collagen implants in a rat model. Comparison of prosthetic materials for abdominal wall reconstruction in the presence of contamination and infection. Negative pres- sure wound therapy to treat hematomas and surgical incisions following high-energy trauma. Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair. Surgical treatment for giant incisional hernia: a qualita- tive systematic review. A retro- spective study evaluating the use of Permacol™ surgical implant in incisional and ventral hernia repair. Mesh location in open ventral hernia repair: a systematic review and network meta-analysis. One year experience of swine dermal non-crosslinked collagen prostheses for abdominal wall repairs in elective and emergency surgery. Primary fascial closure with mesh reinforcement is superior to bridged mesh repair for abdominal wall reconstruction. Long-term outcomes (>5-year follow- up) with porcine acellular dermal matrix (Permacol™) in incisional hernias at risk for infec- tion. Component separation with porcine acellular dermal reinforcement is superior to traditional bridged mesh repairs in the open repair of signifcant midline ventral hernia defects. A critical review of biologic mesh use in ventral hernia repairs under contaminated conditions. Impact of pericar- dium bovine patch (Tutomesh®) on incisional hernia treatment in contaminated or potentially contaminated felds: retrospective comparative study. Long-term outcome of acellular dermal matrix when used for large traumatic open abdomen. Surgisis® in the management of the complex abdominal wall in trauma: a case series and review of the literature. Use of human acellular dermal matrix in complex and contaminated abdominal wall reconstructions. Reconstruction of complex abdominal wall hernias using acellular human dermal matrix: a single institution experience. Multi-institutional expe- rience using human acellular dermal matrix for ventral hernia repair in a compromised sur- gical feld. Use of a non-cross-linked porcine dermal scaffold in abdominal wall recon- struction. Inguinal hernia repair with porcine small intestine submucosa: 3-year follow-up results of a randomized con- trolled trial of Lichtenstein’s repair with polypropylene mesh versus surgisis inguinal her- nia matrix. Catena F, Ansaloni L, Di Saverio S, Cocccolini F, Vallicelli C, Lazzareschi D, et al.
Inhibition of neuropathic pain by decreased expression of the tetrodotoxin-resistant sodium channel best repaglinide 1mg diabetes side effects, NaV1 buy repaglinide with a visa diabetes type 2 clinical trials. Central changes in processing of mechanoreceptive input in capsaicin-induced secondary hyperalgesia in humans repaglinide 2 mg for sale diabetes symptoms headaches. The value of magnetic resonance imaging of the lumbar spine to predict low back pain in asymptomatic subjects: A seven-year follow-up study order repaglinide 1mg without a prescription diabetes quality of life questionnaire. Intervertebral discs which cause low back pain secrete high levels of proinflammatory mediators. Selective inhibition of tumor necrosis factor-alpha prevents nucleus induced thrombus formation, intraneural edema, and reduction of nerve conduction velocity: Possible implications for future pharmacologic treatment strategy of sciatica. 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The effectiveness and risks of fluoroscopically-guided cervical medial branch thermal radiofrequency neurotomy: A systematic review with comprehensive analysis of the published data. A systematic review and best evidence synthesis of the effectiveness of therapeutic facet joint interventions in managing chronic spinal pain. Sacroiliac joint radiofrequency ablation with 4073 probe: a case series of 60 patients. Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Piriformis syndrome: Anatomic considerations, a new injection technique, and a review of the literature. A randomized comparison of the efficacy of 2 techniques for piriformis injection: ultrasound-guided versus stimulator with fluoroscopic guidance. Piriformis syndrome: Comparison of the effectiveness of local anesthetic and corticosteroid injections: A double-blinded, randomized, controlled study. A comparative trial of botulinum toxin A and methylprednisolone for the treatment of myofascial pain syndrome and pain from chronic muscle spasm. Botulinum toxin type A injections for cervical and shoulder girdle myofascial pain using an enriched protocol design. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Cerebrospinal fluid levels of opioid peptides in fibromyalgia and chronic low back pain. A double-blind, multicenter trial comparing duloxetine with placebo in the treatment of fibromyalgia patients with or without major depressive disorder. Sodium oxybate relieves pain and improves function in fibromyalgia syndrome: A randomized, double-blind, placebo-controlled, multicenter clinical trial. Prevention of postherpetic neuralgia: Acyclovir and prednisolone versus epidural local anesthetic and methylprednisolone. Opioids versus antidepressants in postherpetic neuralgia: A randomized placebo-controlled trial. Tramadol in postherpetic neuralgia: A randomized, double-blind, placebo-controlled trial. Pregabalin for the treatment of postherpetic neuralgia: A randomized, placebo-controlled trial. Efficacy of pregabalin in neuropathic pain evaluated in a 12-week, randomised, double-blind, multicentre, placebo- controlled trial of flexible- and fixed-dose regimens. Nortriptyline and gabapentin, alone and in combination for neuropathic pain: A double-blind, randomised controlled crossover trial. No beneficial effect of intrathecal methylprednisolone acetate in postherpetic neuralgia patients. Recommendations for the pharmacologic management of neuropathic pain: An overview and literature update. Validation of proposed diagnostic criteria (the “Budapest Criteria”) for Complex Regional Pain Syndrome.