First Exposure to General Surgery (LANGE First Exposure)

LANGE First Exposure to General Surgery (International Edition)

The authors demonstrated that while the navigation group had greater setup time 9. Radiation exposure, measured in millirems mREM , was also lower in the navigation group undetectable vs Smith et al[ 46 ] noted similar findings in an investigation of 4 cadavers in which lumbar pedicle screw placement was attempted.

The advantages of isocentric 3D C-arm use also extend past limiting radiation exposure, as multiple studies have indicated equivalent or superior accuracy of pedicle screw placement when compared to standard fluoroscopic methods[ 36 , 44 , 46 , 47 ]. O-arm devices can acquire up to images in a single scan, and these images can be utilized with navigation systems to create 3D anatomical reconstructions[ 7 , 48 , 49 ]. The O-arm also is programmed with preset modes that optimize kilovoltage and miliampere settings for various patient sizes and anatomical regions[ 25 , 48 , 49 ].

Similar to the isocentric 3D C-arm, the O-arm can possibly reduce radiation exposure by allowing the surgical staff to exit the operating theatre during image acquisition[ 49 ]. The literature regarding the use of O-arm imaging is mixed in terms of its efficacy in radiation dose reduction. Multiple studies have determined that while O-arm imaging reduces radiation exposure to operative room personnel, it increases the radiation exposure to the patient[ 7 , 17 , 25 , 48 - 50 ].

Tabaraee et al[ 50 ] demonstrated such findings in a cadaveric study investigating the insertion of pedicle screws under either C-arm or O-arm imaging. In the operative room staff, O-arm imaging led to undetectable levels of radiation exposure while C-arm imaging was associated with an exposure of The opposite correlation was seen in cadavers, where the use of the O-arm modality was associated with higher mean radiation doses compared to the use of conventional C-arm fluoroscopy.

Mendelsohn et al[ 17 ] confirmed this association in a matched cohort analysis of patients undergoing posterior pedicle screw insertion. In the 73 patients undergoing a procedure with O-arm imaging, the observed radiation dose in patients was 8.

INTRODUCTION

First Exposure to General Surgery (LANGE First Exposure): Medicine & Health Science Books @ blacksmithsurgical.com Editorial Reviews. About the Author. Danny O. Jacobs, MD is Professor and Chair of Surgery, Duke University Medical Center.

Those patients also experienced a higher mean effective dose of radiation 1. The results of these studies indicate that any practitioner considering the use of O-arm imaging must weigh the benefit of reduced radiation exposure to operative staff with the limitation of increased radiation exposure to patients.

Intraoperative MRI is a developing technology in the field of spine surgery that has the potential for significant reductions in intraoperative radiation exposure both for patients and surgical personnel. Within the spine literature, few studies exist regarding the safety and efficacy of intraoperative MRI. Woodard et al[ 52 ], in a case series consisting of both cervical and lumbar procedures, demonstrated that intraoperative MRI could feasibly be used for localization and confirmation of neural decompression.

Similarly, Choi et al[ 53 ] conducted a study utilizing intraoperative MRI for surgical site localization and confirmation of decompression in 89 patients undergoing percutaneous endoscopic lumbar discectomy. The authors concluded that intraoperative MRI was successful in detecting inadequate intraoperative decompression, especially in cases of highly migrated or segmented discs.

While this initial data is promising, further work is required to definitively determine the efficacy of procedures utilizing intraoperative MRI. While the data supporting the use of intraoperative 3D imaging modalities and navigation systems is promising, these techniques have not yet achieved widespread adoption. In attempting to identify impediments to adoption, multiple studies have been undertaken to survey the opinions of practitioners in the field of spine surgery[ 54 , 55 ].

These investigations consistently identify increased cost, lack of adequate training, and increased associated operative times as factors precluding the use of navigation systems[ 54 , 55 ].

1. Introduction

Costs associated with buying and implementing new imaging and guidance technologies can be burdensome, especially to single-physician and small-group practices. Furthermore, concerns regarding inadequate training extend not only to the surgeon, but to members of the entire operative staff who must adjust to an unfamiliar operative workflow with the introduction of new imaging systems.

Worries about increased operative time are also logical, especially during the initial phase of navigation system adoption when surgical teams are at the beginning of their learning curve. However, recent studies have noted no significant differences in operative time in navigated and non-navigated procedures[ 44 , 50 ].

Nonetheless, manufacturers and proponents of new imaging and navigation systems must still work to overcome the disadvantages of cost, training, and the learning curve to ensure greater adoption of this technology within the field of spine surgery. Radiation exposure is a significant concern for patients, surgeons, and operative room staff. Exposure to ionizing radiation from conventional fluoroscopy is associated with a number of pathologies, the most worrisome being the development of malignancy. As such, radiation safety must be a priority in the operative setting.

All practitioners, irrespective of their practice setting, can and should employ the safety principles of shielding, distance, and dose reduction. Furthermore, practitioners should also consider the use of new navigation systems with alternative imaging modalities such as isocentric-3D C-arm, O-arm, or intraoperative MRI. While these systems may be associated with reductions in radiation exposure to operative staff, they also have significant limitations pertaining to cost, training requirements, and operative times.

Further work is still required within the field of spine surgery to improve radiation safety and to further increase the adoption of new imaging modalities. No benefits in any form have been or will be received from any commercial party related directly or indirectly to the subject of this manuscript. Grade B Very good: Song XX L- Editor: National Center for Biotechnology Information , U. Journal List World J Orthop v. Published online Jul Published by Baishideng Publishing Group Inc.

This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. Abstract Intraoperative imaging is vital for accurate placement of instrumentation in spine surgery. Distance An additional method to reduce intraoperative radiation exposure is to feasibly maximize the distance between the patient surface and the surgeon or operative room personnel[ 18 , 30 ]. Intraoperative MRI Intraoperative MRI is a developing technology in the field of spine surgery that has the potential for significant reductions in intraoperative radiation exposure both for patients and surgical personnel.

Limitations to the adoption of intraoperative 3D imaging While the data supporting the use of intraoperative 3D imaging modalities and navigation systems is promising, these techniques have not yet achieved widespread adoption. Invited manuscript Specialty type: Orthopedics Country of origin: A Grade B Very good: B Grade C Good: January 19, First decision: April 14, Article in press: May 5, P- Reviewer: Comparative results between conventional and computer-assisted pedicle screw installation in the thoracic, lumbar, and sacral spine.

Spine Phila Pa ; Complications of thoracic pedicle screws in scoliosis treatment. Clinically relevant complications related to pedicle screw placement in thoracolumbar surgery and their management: Complications of pedicle screw fixation in scoliosis surgery: Accuracy of free-hand pedicle screws in the thoracic and lumbar spine: The accuracy of 3D image navigation with a cutaneously fixed dynamic reference frame in minimally invasive transforaminal lumbar interbody fusion. Use of CT-based intraoperative spinal navigation: Radiation exposure to the spine surgeon in lumbar and thoracolumbar fusions with the use of an intraoperative computed tomographic 3-dimensional imaging system.

Radiation exposure during pedicle screw placement in adolescent idiopathic scoliosis: Occupational exposure from common fluoroscopic projections used in orthopaedic surgery. J Bone Joint Surg Am. Occupational radiation exposure to the surgeon. J Am Acad Orthop Surg. Radiation exposure to the spine surgeon during fluoroscopically assisted pedicle screw insertion. Surgeon and patient radiation exposure in minimally invasive transforaminal lumbar interbody fusion.

Tissue toxicity induced by ionizing radiation to the normal intestine: Genomic instability induced by ionizing radiation. Ionizing radiation injuries and illnesses. Emerg Med Clin North Am. Patient and surgeon radiation exposure during spinal instrumentation using intraoperative computed tomography-based navigation. Patient and staff dosimetry in vertebroplasty.

Estimation of patient dose and associated radiogenic risks from fluoroscopically guided pedicle screw insertion. Increased cancer risk among surgeons in an orthopaedic hospital. Occup Med Lond ; Cervical spine imaging using mini--C-arm fluoroscopy: J Spinal Disord Tech. Dewey P, Incoll I. Evaluation of thyroid shields for reduction of radiation exposure to orthopaedic surgeons. Aust N Z J Surg.

Operating room radiation exposure in cone beam computed tomography-based, image-guided spinal surgery: Reduction in average fluoroscopic exposure times for interventional spinal procedures through the use of pulsed and low-dose image settings. Am J Phys Med Rehabil. Radiation exposure to the surgeon during percutaneous endoscopic lumbar discectomy: Synowitz M, Kiwit J. Fluoroscopy procedure and equipment changes to reduce staff radiation exposure in the interventional spine suite.

Books For Surgery Rotation

Kruger R, Faciszewski T. Radiation dose reduction to medical staff during vertebroplasty: Effective radiation dose reduction in computed tomography-guided spinal injections: Orthop Rev Pavia ; 4: Int J Med Robot. Navigation at the spine. Placement of thoracolumbar pedicle screws using three-dimensional image guidance: Comparison of the percutaneous screw placement precision of isocentric C-arm 3-dimensional fluoroscopy-navigated pedicle screw implantation and conventional fluoroscopy method with minimally invasive surgery.

General anesthesia exposure in early life reduces the risk of allergic diseases

Three-dimensional fluoroscopy-guided percutaneous thoracolumbar pedicle screw placement. Intraoperative computerized tomography for improved accuracy of spinal navigation in pedicle screw placement of the thoracic spine. However, modern environments lacking microbial or inflammatory exposure may cause an abnormal persistence of the Th2 immunity resulting in allergy.

Supporting this hypothesis, prior studies have found that surgery-related postoperative release of pro-inflammatory cytokine IL-6 was increased in patients after spinal and GA. The inhalation anesthetic agents are either methyl-ethyl or isopropyl ether class. It is believed that GA may affect the regulatory balance of postoperative immune response. Partially because of neonatal respiratory morbidity, preterm births are associated with an increased risk of asthma-like symptoms, [ 28 ] and prematurity and low birth weight are significantly related to the decreased occurrence of AR in male conscripts.

Moreover, the most common etiologies of received surgery are inguinal hernia, [ 32 ] redundant prepuce, phimosis, tongue tie, and hydrocele that are male predominant and that is consistent with our results of GA group. As a result, prematurity or low birth weight may considerably influence the risk of subsequently developing allergic diseases; these 2 factors presented as ICD and sex have been adjusted in this study. Additional studies are warranted to explore the mechanism about changes in the immune system caused by GA exposure and their long-term effects influencing the subsequent development of allergic diseases in humans.

This study is the first to investigate the allergic disease risk in children after having GA by using a population-based study, as well as the first to find that children who had early GA exposure before 1 year of age had reduced risk of subsequently developing allergic disease such as asthma, AD, and AR when compared with the general population.

None of the authors have a financial relationship to disclose with regard to this article. The authors report no conflicts of interest. National Center for Biotechnology Information , U. Journal List Medicine Baltimore v. Published online Jul Find articles by Jyun-Hong Jiang. Published by Wolters Kluwer Health, Inc. This is an open access article distributed under the Creative Commons Attribution License 4. Abstract General anesthesia GA has been used for second line treatment strategy for status asthmaticus in pediatric patients.

Introduction The increasing global incidences of allergic diseases, including asthma, allergic rhinitis AR , and atopic dermatitis AD , are important health problems for children. Statistical analysis The person-years of follow-up for each case were calculated from the date of diagnosis of allergic disease to the date of death, or December 31, Table 1 General characteristics of the study subjects.

Open in a separate window. Table 2 Risk of allergic diseases of children with a history of general anesthesia exposure. Discussion Children who were exposed to GA in early life of less than 1 year of age had decreased risk of developing allergic diseases including asthma, allergic rhinitis, and atopic dermatitis. Conclusions This study is the first to investigate the allergic disease risk in children after having GA by using a population-based study, as well as the first to find that children who had early GA exposure before 1 year of age had reduced risk of subsequently developing allergic disease such as asthma, AD, and AR when compared with the general population.

Factors associated with the development and remission of allergic diseases in an epidemiological survey of high school students in Japan. Am J Rhinol Allergy ; Monoclonal antibodies in allergy; updated applications and promising trials.

Increased risk of atopic dermatitis in preschool children with kawasaki disease: Evid Based Complement Alternat Med ; Economic burden of inadequate management of allergic diseases in the European Union: Addition of long-acting beta2-agonists to inhaled corticosteroids for chronic asthma in children. Cochrane Database Syst Rev ; Carrie S, Anderson TA. Volatile anesthetics for status asthmaticus in pediatric patients: Paediatr Anaesth ; Isoflurane therapy for severe refractory status asthmaticus in children.

Intensive Care Med ; Wasowicz M, Jerath A. Expanding the use of volatile anesthetic agents beyond the operating room.

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Similarly, Choi et al[ 53 ] conducted a study utilizing intraoperative MRI for surgical site localization and confirmation of decompression in 89 patients undergoing percutaneous endoscopic lumbar discectomy. Effective radiation dose reduction in computed tomography-guided spinal injections: In order to mitigate the risk associated with intraoperative radiation exposure, new imaging technologies and personal protective equipment have been developed. Eur J Anaesthesiol ; Collimation refers to narrowing the radiation beam over the area of anatomic interest, thus reducing radiation exposure by subjecting less total body area to interaction with radiation[ 26 , 31 ]. Paediatr Anaesth ;

Can J Anaesth ; Inhalational anesthetics in acute severe asthma. Curr Drug Targets ; Health Aff Millwood ; Kawasaki disease and subsequent risk of allergic diseases: BMC Pediatr ; Population-based study of the association between urbanization and Kawasaki disease in Taiwan. An anesthesiologist's perspective on inhaled anesthesia decision-making. Immune modulation for treatment of allergic disease. Immunol Rev ; Sheeran P, Hall GM. Br J Anaesth ; Immunomodulatory effects of total intravenous and balanced inhalation anesthesia in patients with bladder cancer undergoing elective radical cystectomy: J Exp Clin Cancer Res ; Effect of spinal and general anesthesia on serum concentration of pro-inflammatory and anti-inflammatory cytokines.

The effect of anaesthesia and surgery on plasma cytokine production. Desflurane but not sevoflurane impairs airway and respiratory tissue mechanics in children with susceptible airways. Katoh T, Ikeda K. A comparison of sevoflurane with halothane, enflurane, and isoflurane on bronchoconstriction caused by histamine. Protective effects of volatile agents against methacholine-induced bronchoconstriction in rats. Effects of different anaesthetic agents on immune cell function in vitro.