Booster Shots

Oddities, musings and news from the health world

Category: surgery

Gallbladder removed through mouth in new surgical technique

July 8, 2010 |  6:00 am

As part of the trend in developing surgeries without external wounds, surgeons last week removed a woman's gallbladder through her mouth. The operation was performed as part of a clinical trial at UC San Diego School of Medicine.

The surgery is called NOTES -- which stands for natural orifice translumenal endoscopic surgery. The idea is to use the mouth or vagina as routes to parts of the body requiring surgery. In traditional laparoscopic -- or minimally invasive -- surgery, doctors make several small incisions through the abdominal wall and insert a tiny camera and tools to remove the gallbladder or appendix. That type of surgery is a big improvement upon the long, open incisions that patients used to require.

However, NOTES spares patients even the tiny abdominal incisions. Tools are passed down the mouth and through a hole created in the stomach. In the recent surgery, lead investigator Santiago Horgan made two tiny incisions (not requiring stitches) to pass a camera into the abdomen to increase visibility. However, the gallbladder was removed by way of the mouth.

The procedure was done as part of a study that will evaluate the safety and efficacy of NOTES compared with  laparoscopy as well as the pain levels, cosmetic outcome, costs and other outcomes, Horgan said in a news release. Horgan is the director of UCSD's Center for the Future of Surgery. The hope is that natural orifice procedures will reduce the risk of infection and pain as well as abdominal scars. The center also performed the first oral appendix removal.

-- Shari Roan

Surgery to repair ACL and meniscus injuries may not reduce osteoarthritis risk

June 29, 2010 |  1:03 pm

Torn anterior cruciate ligaments and menisci, common knee injuries, are often repaired by surgery. But those surgical repairs won't necessarily stave off osteoarthritis, says a new study.

L4lhnunc The study, published online and in the August issue of the journal Radiology, focused on 326 men and women who were part of a previous 855-person study from 1996 to 1997 comparing the use of MRIs to arthroscopy as diagnostic tools for knee pain. ACL tears and ruptures are common knee injuries, especially for those who engage in sports. Having an ACL injury can cause a chain of deleterious events in the knee, including damage to the meniscus, a wedge of cartilage that reduces friction between joints when they move. The ACL is one of four major knee ligaments.

Following up about 10 years later with patients from the original study, researchers found that people who had had ACL ruptures had greater risk of developing a number of complications associated with osteoarthritis, including joint space narrowing, bone marrow lesions, and subchondral cysts, which occur near joints. Patients with a torn meniscus had similar higher risks.

Osteoarthritis developed despite treating some of the injuries with surgery.

"There is a higher risk of developing knee osteoarthritis at specific sites after tearing a meniscus or cruciate ligament," said lead author Dr. Kasper Huetink in a news release. Huetink, resident radiologist at Leiden University Medical Center in the Netherlands, added, "We showed a direct relationship between injury and long-term consequences, and showed that surgery has no impact on long-term outcomes."

-- Jeannine Stein

Photo credit: Anne Cusack / Los Angeles Times

Waiting period for weight-loss surgery is useless, study says

June 26, 2010 |  8:00 am

Obesetape People who are slated to undergo weight-loss surgery are often required by their health insurance company to wait six months from the time of approval to the time of surgery. The wisdom behind the waiting period is that patients should use the time to try to adapt to new diet and exercise habits that will be essential to their long-term success.

A study presented Saturday at the annual meeting of the American Society for Metabolic & Bariatric Surgery suggests that the waiting period is ineffective. Researchers followed 440 people who had either laparoscopic gastric bypass or laparoscopic adjustable gastric banding. Of these, 116 people were required by their health insurance plan to wait six months. The study showed there was no significant difference between the two groups in weight loss prior to surgery or one year after surgery.

According to the study's author, Dr. Timothy Kuwada of the Carolinas Medical Center in Charlotte, N.C., typically all patients receive nutritional and psychological counseling about their post-surgical lifestyle in advance of the surgery. That approach is sufficient, he suggests. However, given the cost of surgery and the importance of lifestyle changes to success, it doesn't seem unreasonable for insurers to ask that patients prepare for the surgery and its aftermath -- whether that takes one month or six.

In another study presented Saturday at the meeting, researchers found that gastric bypass surgery restored levels of low-density lipoprotein -- or bad -- cholesterol to normal in 91% of patients within six months of the surgery and that these patients remained off medication six years later. Also, six years after the surgery, levels of HDL, or good, cholesterol, had increased by more than 10%. The study was conducted at the University of Iowa Hospital and Clinics.

-- Shari Roan

Photo credit: Karen Tapia-Andersen / Los Angeles Times

Have weight-loss surgery with a relative for best success

June 25, 2010 |  6:00 am

Womanobese People who undergo gastric bypass surgery at the same time as a family member are likely to succeed far better than people who undergo the surgery alone, according to a study released Friday at the annual meeting of the American Society for Metabolic & Bariatric Surgery.

Prior research shows that having an exercise partner helps people stick to their workout regimen and accrue greater health benefits from exercise. It appears that the same dynamic can work for people having bariatric surgery. Researchers from the University of Medicine and Dentistry in New Jersey-Robert Wood Johnson Medical School followed 91 patients from 41 families who had surgery with a sibling, parent, child, spouse, cousin, grandmother, granddaughter, in-law, aunt, uncle, nephew or niece. They were compared with similar patients who had surgery alone.

After one year, the family members lost, on average, about 30% more of their excess weight than did the control group. Siblings, in particular, fared especially well. They lost about 40% more of their excess weight compared with the control group.

"Clearly the family dynamic, even a little sibling rivalry, can play an important role in patient success," the lead author of the study, Dr. Gus J. Slotman, said in a news release. "Family members are a built-in support system that can help turn a good result into a great result, particularly the first year after surgery, when adjusting to a new lifestyle and dietary requirements can be challenging."

In another study presented Friday at the meeting, researchers found that female patients have fewer complications and shorter hospital stays compared with male patients undergoing laparoscopic gastric bypass. The study of nearly 38,000 people also showed that Latinos and Caucasians have fewer complications than African Americans, and that younger patients do better than older ones. The research was performed at the University of Nebraska Medical Center.

— Shari Roan

Photo credit: Lisa Maree Williams / Getty Images

Patients denied weight-loss surgery don't get any healthier

June 24, 2010 |  8:00 am

Obeseart Not all health insurance companies cover weight-loss, or bariatric, surgery -- especially if the patient's obesity isn't considered "severe" enough. A study released Thursday, however, offers a glimpse of what happens to people who want weight-loss surgery but are denied it.

Within three years of being denied surgery, patients developed a range of obesity-related diseases compared to a group of similar patients who received surgery. Researchers from Gundersen Lutheran Health System in La Crosse, Wis., examined the records of 587 patients who had laparoscopic gastric bypass with 189 patients who were medically eligible (meaning they were obese enough according to medical guidelines) but whose insurers denied the surgery. The average body mass index of the patients in both groups was 48. A BMI of 30.1 or higher is considered obese; a BMI of 35 to 40 is called Class II obesity and over 40 is considered Class III obesity.

After three years, the average BMI in the surgical group had dropped to 30.5 and less than 1% of patients had developed new obesity-related conditions. The patients who did not have surgery had BMIs that were, on average, unchanged. However, 40% had gone on to develop hypertension, 34% developed obstructive sleep apnea and 20% developed gastroesophageal reflux disease. Others developed diabetes or high cholesterol.

The research was presented Thursday at the annual meeting of the American Society for Metabolic & Bariatric Surgery.

"It is well-known that bariatric surgery treats obesity-related disease," the lead author of the study, Dr. Shanu N. Kothari said in a news release. "Our study now shows that it can prevent new diseases from occurring."

Only about 1% of Americans who are clinically eligible for bariatric surgery because of morbid obesity undergo surgery.

-- Shari Roan

Image credit: T: Joseph Daniel Fiedler / For the Times

Angioplasty plus stents is as good as surgery for clearing neck arteries, study finds

May 26, 2010 |  2:10 pm

A combination of angioplasty and stenting are as good as the gold standard of surgery for clearing fat deposits from neck arteries and keeping them open, researchers reported Wednesday. The findings in the NIH-funded trial, which included more than 2,500 patients, contradict the findings from smaller European trials which concluded that stenting is riskier.

The results, reported at a meeting in February and published in the New England Journal of Medicine on Wednesday, show that the two procedures are virtually equivalent, but that patients who undergo stenting tend to have more strokes in the months after the procedure, while those who undergo surgery tend to have more heart attacks. "Which complication would you prefer?" asked Dr. Christopher White of the Ochsner Heart & Vascular Institute in New Orleans, a spokesman for the Society for Cardiovascular Angiography and Interventions. "The answer is, I don't want either one." As a cardiologist, he wants to match one procedure or the other to the patient to minimize complications. "That's why I, as a clinician, need freedom to pick and choose, and I currently don't have that freedom" because Medicare and many insurance companies do not reimburse for stenting of the neck artery.

Experts hope the new results from the study known as CREST will convince Medicare to change its reimbursement policies. That change might also be helped along by new guidelines on choosing between the two surgeries to be issued this summer by SCAI and the Society for Surgery.

"We now have two safe and effective methods to treat carotid artery disease that can be targeted to individual patients," Dr. James Meschia, a neurologist at the Mayo Clinic in Jacksonville and one of the study's principal co-authors, said in a statement

An estimated 700,000 Americans suffer strokes each year, and the bulk of those incidents are caused by the buildup of plaque in the carotid arteries, the primary vessels in the neck that carry blood to the brain. The plaque can build up to the point where it completely blocks blood flow, or pieces can break off and lodge in smaller vessels in the brain.

The gold standard for treatment of the condition is surgery to scrape the plaque out of the artery, a process called carotid endarterectomy. About 150,000 of the procedures are performed in the United States each year. A newer procedure is to insert a catheter through the groin and thread it to the neck, where a balloon is inflated to compress the plaque and a wire mesh spring called a stent is inserted to prevent the plaque from re-expanding. They are less invasive, require a shorter hospital stay and are cheaper, but some have questioned their safety.

The CREST (Carotid Revascularization Endarterectomy vs. Stenting Trial) study, led by Dr. Thomas G. Brott of the Mayo Clinic, enrolled 2,502 patients at 117 centers in the United States and Canada between 2000 and 2008. They were randomly assigned to undergo either surgery or stenting.  The study was conducted in large and small, public and private hospitals. "The idea was to design a study that reflects the U.S. experience," he said in a statement.

The chief difference between the U.S. and European studies, White said, is that those who performed the stenting procedure in this country were required to demonstrate proficiency with the technique before the trial began, while those who performed it in Europe were "novices" who had just been taught the technique. "Which is ridiculous," he said. "How can you compare procedures when you are teaching how to do one and have an expert on the other side?" White, it should be noted, is a stenter.

Overall, 4.1% of patients in the stenting group had strokes in the weeks after the procedure, compared with 2.3% of those who had surgery. But 2.3% of those in the surgical group had heart attacks, compared with 1.1% of those with stents. The results were similar whether or not the patients had displayed symptoms before the operation.

The higher incidence of strokes for stenting is misleading, White said. "Not all strokes are the same. For big, damaging strokes, there was no difference between surgery and stenting. The difference was in minor strokes," from which patients generally recover with no significant problems.

The results do provide some general guidelines for how to choose between the two approaches. Patients in CREST who were over 70 tended to do better with surgery, perhaps because their arteries are less flexible. Those under 70 did better with stenting. People with cardiovascular disease are likely to do better with stenting, but those with hardened or "twisty" arteries are more likely to do better with surgery.

"Local experience is also important," White said. "If you don't have someone who is an expert at stenting, I would favor surgery. Procedures tend to be things that are learned, developed and in which people develop expertise.... I would prefer not to be treated by a beginner."

Abbott Laboratories, whose stents were used in the study, said it would use the data to apply to the Food and Drug Administration to market the stents to most patients with problematic carotid arteries. The stents are now approved only for use in patients who are at high risk from surgery due to anatomical factors, age or other considerations.

-- Thomas H. Maugh II

Sinus surgery becoming more popular. But is it better?

May 18, 2010 | 11:06 am

Minimally invasive sinus surgery is becoming a common option to treat chronic sinusitis, appearing to replace many nonsurgical alternatives such as antibiotic therapy, intranasal steroids and nasal saline irrigation. However, there is a lack of scientific data to show that surgery is a better option than medical therapies.

Sinus Chronic sinusitis is a condition that includes congestion, runny nose, headache, facial pressure and other symptoms lasting three months or more. It is a leading cause of doctor's office visits in the United States. Minimally invasive sinus surgery, in which small instruments and a lighted tube are inserted through the nose to remove abnormal tissue or obstructions, was introduced in the United States in 1985. Researchers at Dartmouth-Hitchcock Medical Center looked at the popularity of treatment of chronic sinusitis in a group of Medicare beneficiaries from 1998 to 2006. They found the rate of surgery increased 20% while the actual rate of the condition did not increase. The more traditional form of sinus surgery, open surgery, declined during that time.

The introduction of a minimally invasive surgery often increases interest in the surgical treatment of a problem, perhaps replacing medical treatments that might work just as well, the authors suggest.

"Endoscopic sinus surgery has been a revolutionary technology and has the potential to improve the poor quality of life of patients with rhinosinusitis with markedly less morbidity relative to open approaches," the authors wrote. But, they add, without long-term studies comparing surgery with medical treatments "the appropriate rate of endoscopic sinus surgery remains unknown."

The study was released Monday in the Archives of Otolaryngology, Head and Neck Surgery.

-- Shari Roan

Two types of urinary incontinence sling surgeries are comparable

May 17, 2010 |  2:38 pm

Two types of "sling" surgeries are popular for treating female urinary incontinence. According to a study published Monday, both operations show satisfactory results 12 months after surgery, although each approach has unique side effects and complications that women and their doctors should consider.

Urinary incontinence affects as many as half of all women, to varying degrees. An estimated 4% to 10% of these women seek surgery to treat the problem, although exercises, medications and non-surgical treatments are available. Sling surgery uses strips of synthetic material, mesh or natural tissue to keep the urethra closed. The study, released today in the New England Journal of Medicine, compared the retropubic sling surgery to the transobturator midurethral sling. Basically, the surgeries vary in how they're performed.

Almost 600 women were assigned to undergo one of the two procedures. They were followed for one year and underwent subjective and objective tests to gage the surgery effectiveness. The study found subjective success scores of 62.2% for the retropubic sling group and 55.8% for the transobturator sling. But 2.7% of the first group reported voiding problems that required surgery compared to no such cases in the transobturator group. Women in the transobturator group were more likely to report numbness and weakness from the sling.

Surgery success also depends on the surgeon's experience, said Dr. Rebecca G. Rogers, of the University of New Mexico Health Science Center, writing in a commentary accompanying the study. Moreover, more information is needed on the long-term success of slings. "Up to a third of women who have surgery for stress incontinence undergo a second procedure during their lifetime, and data regarding the long-term effectiveness and equivalence of these two procedures are critical to decision making," she noted.

— Shari Roan

A questionable increase: Complex spinal fusion surgeries soar

April 6, 2010 |  1:00 pm

Spine In just five years, from 2002 to 2007, the number of complex fusion surgeries to treat spinal stenosis of the lower back soared from a rate of 1.3 per 100,000 to 19.9 per 100,000, according to a study released Tuesday in the Journal of the American Medical Assn. Complex spinal fusion involves joining several vertebrae and can also include removing disks, bone or bone spurs.

During that same time period, the rates of decompression surgery (relieving pressure on the spine) and simple fusion procedures (joining just one or two vertebrae) decreased. The study was done among Medicare recipients.

Stenosis is a condition in which the spinal canal narrows and compresses the spinal cord and nerves. It is not a simple thing to either correctly diagnose or treat. Studies show that decompression surgery is often beneficial over doing nothing. However, more complex surgeries are increasingly preferred by physicians, and these surgeries carry more risk. The study showed that complications occurred in 2.3% of patients having decompression alone to 5.6% in patients having complex spinal fusions. Patients who had complex fusion had three times the rate of life-threatening complications, had longer hospitalizations and higher rates of re-hospitalization.

Finally, there is the money. Complex fusion operations cost, on average, $80,888 in hospital charges compared with $23,724 for decompression.

In an editorial accompanying the study, Dr. Eugene J. Carragee of Stanford University cautions patients to compare decompression with other treatments, which may be unproven. But, he notes, the income generated by the more complex surgeries can make it difficult for patients to receive a "careful assessment" of all of the alternatives.

-- Shari Roan

Photo credit: Stephen J. Carrera  /  Los Angeles Times

So what does knee replacement look like? Valve repair? Vasectomy reversal?

March 16, 2010 |  3:32 pm

Basketball Knee replacement and hip resurfacing don't have to mean the end of that go-go-go lifestyle, as Jeannine Stein reported earlier Tuesday on Booster Shots. But promises of an active existence aside, not knowing what to expect from the surgery can make even the most pain-riddled patients reluctant to say goodbye to the joints with which they were born.

Time for a visit to the surgery video library! (If you dare....) The ever-reliable MedlinePlus offers a variety of surgical videos from which to choose. Each has interviews, medical explanations and, of course, scenes of the procedure in question. There are 10 in the knee replacement category alone (here's one), but why stop there?

You can also watch a hip replacement (complete with hammer pounding away at the joint), mitral valve repair, laparoscopic adrenalectomy, vasectomy reversal, living donor kidney transplant .... 

These are not videos for those easily made squeamish. But they are enlightening.

As for that go-go-go lifestyle, here's the earlier blog post. Assuming you can watch the video of your choice without losing the desire to get off the couch, much less play sports, it's yours for the taking.

 -- Tami Dennis

Photo: Want to do this again? Time to learn what's required... 

Credit: Associated Press


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