Ten-year trends in Canada for selected operations

Of 16 operations common in Canada the national rates over a 10-year period for the 9 discretionary procedures varied much more than those for the nondiscretionary operations. The rates of tonsillectomy and adenoidectomy, hemorrhoidectomy, varicose vein stripping and appendectomy decreased substantially, whereas those of extraction of lens, cesarean section and colectomy increased. The rates of hysterectomy and cholecystectomy first increased and then decreased. With the exception of Newfoundland the provinces generally followed these trends. Neither the Canadian nor the provincial rates were significantly associated with the availability of hospital beds or surgeons. Factors other than resources probably accounted for much of the variation among the provinces.     

Five-year study of surgical rates in Ontario's counties.

The surgical rates for eight operations (hysterectomy, tonsillectomy/adenoidectomy, cholecystectomy, prostatectomy, appendectomy, mastectomy, colectomy and cesarean section) done in Ontario''s 44 counties from 1973 to 1977 were examined. There was considerable variation among the counties for all the operations studied, although the degree of intercounty variation decreased over the 5 years. Differences in resources (hospital beds and surgeons) explained little of the variation in the rates, but this may be because people crossed county lines for certain operations. Although some counties had consistently high or low rates for individual operations during the 5-year period, only four had consistently high rates for four or more operations, and only five had consistently low rates for four or more. The five counties with teaching health science centres had the highest ratios of specialists and surgeons to population, and, with the exception of one county in 1973, had above-average numbers of hospital beds. Despite the greater resources in these counties, their residents had consistently low rates for cholecystectomy, appendectomy, mastectomy and tonsillectomy/adenoidectomy. However, three of these counties had the highest rates for cesarean section. The variation in the rates is likely due to lack of agreement about indications for surgery or to variation in the use of technology rather than to differences in the incidence or prevalence of disorders.     

Measures of early postoperative mortality: beyond hospital fatality rates.

OBJECTIVE--To quantify the short term risk of postoperative mortality in ways which take account of deaths after discharge and the background risks of death in patients who come to operation. DESIGN--Analysis of linked abstracts of hospital admission records and death certificates for common operations. SETTING--Six health districts in the Oxford region. SUBJECTS--Records of 223,529 operations performed in 1980-6. MAIN OUTCOME MEASURES--In hospital fatality rates, case fatality rates, and standardised mortality ratios at selected time periods during the year after operation and the ratio of early (< 30 days) to late (90-364 days after operation) fatality rates. RESULTS--Fatality rates throughout the year after operations performed after emergency admissions were generally higher than those for similar operations performed after elective admissions and higher than expected from population rates. Examples were prostatectomy, hip arthroplasty, inguinal herniorrhaphy, and cholecystectomy. Common elective operations such as inguinal herniorrhaphy and cataract operations showed no early peak in mortality, but others did. These included transurethral prostatectomy (ratio of early to late mortality 2.0; 95% confidence interval 1.3 to 2.6), hysterectomy (3.2; 1.5 to 6.6), hip arthroplasty (3.8; 2.5 to 5.4), and cholecystectomy (6.9; 4.3 to 11.1). CONCLUSIONS--Temporal profiles of death rates in the year after operation show which operations have early peaks in mortality and which do not. Emergency and elective operations have very different profiles and should be analysed separately. For elective operations for conditions which pose no immediate threat to life the ratio of early to later fatality rates provides a measure of increase in mortality after operation while allowing for the background risk of death in the patient groups.     

Measuring surgical decision-making with hypothetical cases

Hypothetical clinical cases were used to investigate surgical decision-making in relation to surgical rates across Ontario. Six procedures were studied (cholecystectomy, colectomy, inguinal herniorrhaphy, hysterectomy, cesarean section and tonsillectomy-adenoidectomy), and substantial differences of opinion regarding the choice of surgical or nonsurgical treatment were recorded. The decision to operate, however, was not made more frequently in Ontario counties with high operative rates, and none of the demographic variables studied were correlated with the decision to operate. Other variables that might have affected operative rates were not taken into account. There were also differences of opinion in referral decisions, but generally internists and pediatricians were less likely to refer the hypothetical cases to surgeons than were family physicians.     

改良曲张静脉点式剥除术治疗中老年下肢静脉曲张的临床疗效

目的:探究改良曲张静脉点式剥除术在治疗中老年下肢静脉曲张的临床疗效。方法:收集我院已确诊为下肢静脉曲张的中老年患者37例,分成实验组与对照组。对照组18例行传统曲张静脉点式剥除术,实验组19例行改良曲张静脉点式剥除术。对比两组患者手术后的下肢静脉曲张的治疗效果。结果:实验组有效率(94.7%)显著高于对照组(72.2%),差异具有统计学意义(P0.05);与对照组相比,实验组患者手术时间较短、术中出血量较少、下床活动时间较早,术后并发症总治愈率较高,复发率、术后并发症发生率较低,其差异均有统计学意义(P0.05)。结论:采用改良曲张静脉点式剥除术治疗中老年下肢静脉曲张的患者能够更彻底的剥除曲张额静脉,有效的改善患肢症状,明显降低复发率。     

Tonsillectomies: in dollars and cents

Over the last quarter of a century, much controversy has been generated on the indications for tonsillectomy and adenoidectomy. The economic aspects of this operation have received comparatively little attention. The rate per 10,000 children 0 to 19 years of age for the whole province of Ontario for the year 1971 was 174 and ranged from a high of 307 in one county to a low of 59 in another. The total cost of these operations to the health insurance plan was 11.4 million dollars. National studies on the indications for these operations, their benefits and hazards are urgently required.     

Incidence of poliomyelitis; the effect of tonsillectomy and other operations on the nose and throat

A statistical survey was made of all the cases of poliomyelitis occurring in all of Los Angeles County during the three years of 1949, 1950 and 1951 in an attempt to determine the effect of operations on the nose and throat on the incidence of poliomyelitis. Tonsillectomy and adenoidectomy were the only operations noted with any degree of frequency. Yet, in the total of 3,601 cases of poliomyelitis that occurred in this three-year period there were only 20 (0.55 per cent) in which the patient had had recent tonsillectomy and adenoidectomy. The incidence of this disease in patients who had had tonsillectomy and adenoidectomy was compared with the "expected" incidence as determined from the incidence in other patients, in the same age group. There was no significant difference between actual and expected incidence even during the summer months when most cases of poliomyelitis occurred. The same was true with regard to recently tonsillectomized patients in the epidemic months of July through October. In a separate survey of 675 patients with poliomyelitis, it was noted that only 30 per cent ever had had tonsillectomy or adenoidectomy. Inasmuch as it is estimated that one of every three persons in the general young population nowadays has had tonsillectomy and adenoidectomy, this figure is no more or less than could be expected.     

A CONTROLLED TECHNIQUE FOR VEIN STRIPPING

A number of difficulties encountered in vein stripping operations for varicose veins in the legs have been overcome by use of a technique evolved by adaptation and modifications of various reported methods.The stripping instrument is passed from below upward, the valves or branches offering less impediment to its passage in that direction.Inserting the tip of the instrument at the ankle through an incision in the vein while it is still in continuity is easier than introducing it into the end of a transected vein. Ligation of major superficial branches or subfascial division of communicating veins can be readily carried out while the stripper is still in place in the vein.Applying pressure bandages to the entire length of the leg before removing the stripper and the telescoped vein diminishes the chances of ecchymosis yet does not hinder withdrawal of the instrument and the vein.     

Chronic otitis media with effusion (glue ear) and adenotonsillectomy: prospective randomised controlled study.

A prospective study was conducted of the effects of adenoidectomy and adenotonsillectomy on established otitis media with effusion unresponsive to medical treatment. The operations were performed at random with a controlled no surgery group on a cohort of 103 children with the condition and the results assessed six weeks, three months, six months, nine months, and one year later. After adenoidectomy the rate of resolution of the condition increased from 39% at six weeks to 72% at one year; and after adenotonsillectomy the rate increased from 59% at six weeks to 62% at one year. In the no surgery group the rate increased from 16% at six weeks to 26% at one year. Compared with the no surgery group the effect of adenoidectomy alone at one year was highly significant (p less than 0.001), and similarly the effect of adenotonsillectomy was significant (p less than 0.01). There was, however, no increased benefit from the addition of tonsillectomy compared with adenoidectomy alone. Thus there was resolution of 36-46% of chronic effusions as a result of adenoidectomy.     

Has laparoscopic cholecystectomy changed patterns of practice and patient outcome in Ontario?

OBJECTIVE: To examine the effect of the introduction of laparoscopic cholecystectomy (LC) on patterns of practice (number of cholecystectomy procedures, case-mix and length of hospital stay) and patient outcomes in Ontario. DESIGN: Cross-sectional population-based time trends using hospital discharge data. SETTING: All acute care hospitals in Ontario where cholecystectomy was provided. PATIENTS: All 119,821 Ontario residents who underwent cholecystectomy between 1989-90 and 1993-94. After exclusions (initial bile duct exploration, cancer, incidental cholecystectomy, or missing codes for age, sex or residence) 108,442 patients remained. OUTCOME MEASURES: Number of cholecystectomy procedures, proportion of patients with acute or chronic gallstone disease, length of hospital stay, and rates of death, readmission, and bile duct injury and other in-hospital complications after cholecystectomy by year. RESULTS: The number of cholecystectomy procedures increased by 30.4% between 1989-90 and 1993-94. The number of patients with chronic gallstone disease increased by 33.6%, and the number who underwent elective surgery increased by 48.3%. The proportion of procedures performed as LC increased from 1.0% in 1990-91 to 85.6% in 1993-94. Patients who received LC tended to be younger female patients with chronic gallstone disease with no coexisting conditions undergoing elective operations. The mean length of stay, adjusted for case-mix differences, was significantly lower in 1993-94 than in 1989-90 (2.6 days v. 7.5 days) (p < 0.05); the values for LC and open cholecystectomy in 1993-94 were 1.8 days and 7.3 days respectively. The decrease in the crude death rate over the study period (0.3% to 0.2%) was not significant (relative odds 1.10, 95% confidence interval [CI] 0.72 to 1.69). In 1993-94 the adjusted risk of readmission to hospital within 30 days was 1.38 (95% CI 1.19 to 1.58) as compared with 1989-90. Over the 5 years the rate of bile duct injuries tripled (0.3% in 1989-90 v. 0.9% in 1993-94). The adjusted risk of having at least one complication after cholecystectomy in 1993-94 was 1.90 (95% CI 1.75 to 2.07) as compared with 1989-90. CONCLUSIONS: LC has had a substantial effect on the number of cholecystectomy procedures performed, the type of patient having the gallbladder removed and the length of hospital stay. Death rates are unchanged, but the odds of readmission and in-hospital complications are both increased. Future research should be directed toward determining the reasons for the overall increase in rates, developing methods to reduce bile duct injuries and identifying other relevant outcomes, such as patient satisfaction with the procedure.     

Education,practice reviews needed to reduce surgical intervention,Quebec report says.

Clinical uncertainty may be the reason for large variations in the rates of tonsillectomy, adenoidectomy and myringotomy in Quebec, a report prepared for the provincial government states. Methods used in other jurisdictions, such as informing physicians about geographic differences in intervention rates and developing clinical practice guidelines, could reduce the variations and save millions of dollars, researchers suggest.     

手术治疗摩洛哥儿童睡眠呼吸障碍的临床研究

目的:观察鼻内镜下腺样体切除术或联合扁桃体切除术对摩洛哥儿童睡眠呼吸障碍的疗效,探讨儿童睡眠呼吸障碍治疗的手术适应症。方法:136例病例分成2组,治疗组85例睡眠呼吸障碍伴慢性扁桃体炎、或扁桃体Ⅲ°肥大的儿童,行鼻内镜下腺样体切除加扁桃体切除术;对照组51例睡眠呼吸障碍伴单纯扁桃体扁桃体Ⅱ°肥大的儿童,采用鼻内镜下腺样体切除,术后随访3个月。结果:治疗组总有效率为100%(85/85),对照组84.31%(43/51),差异有统计学意义(P0.05);两组患儿的Conners儿童行为量表评分较术前明显下降,差异有统计学意义(P0.05)。结论:鼻内镜下腺样体切除术联合扁桃体切除术,明显改善患儿睡眠和呼吸,生活质量明显提高,是治疗摩洛哥儿童睡眠呼吸障碍的一线治疗方案。     

Incidence and estimated need of caesarean section,inguinal hernia repair,and operation for strangulated hernia in rural Africa.

Numbers of caesarean sections, inguinal hernia repairs, and operations for strangulated hernia performed in 1979-81 at 10 rural hospitals in eastern Africa were matched against estimated populations in the respective catchment areas. Annual rates of each operation varied considerably between hospitals, the averages being: for caesarean sections 25 per 100 000 per year; for inguinal hernia repairs 25 per 100 000 per year; and for operations for strangulated hernia four per 100 000 per year. The estimated minimum needs for these operations, based on available data for morbidity were 225, 175, and 30 per 100 000 per year, respectively. Numerous deaths and cases of permanent disability occur in remote rural villages because common conditions requiring urgent surgery are neither prevented nor properly cared for. A balanced improvement of both primary and secondary care in rural Africa is needed.     

Varicose veins as a source of adult human endothelial cells

Endothelial cells can be harvested from segments of adult human saphenous vein in a varicose condition removed from patients having single or bilateral vein ligation and stripping. The cells are harvested by scraping with a scalpel, seeded on to gelatin coated or Primaria flasks and are passaged by removal with a rubber policeman. The cells cultured in this manner are maintained in a growth medium that is not supplemented with growth factors. The cells grow with a cobblestone monolayer morphology, possess angiotensin converting enzyme activity and react with antibodies to Factor VIII antigen. The cells fluoresce brightly after reaction with monoclonal antibodies specific for human endothelial cells. Thus, stripped varicose vein segments provide a readily available source of endothelial cells.     

VARICOSE VEINS—A Practical Approach to Treatment

Adequate treatment of varicose veins requires thorough mapping of perforating veins, communicating veins and “blow out” areas. Combined ligations, stripping and injection of sclerotic substances after operation is the most effective regimen of therapy.The technique of stripping is facilitated by isolating the saphenous vein at the ankle, inserting the stripper from below upward, then making a transverse groin incision over the palpable stripper. The tip of the stripper should be twice the diameter of the vein to be removed. Stripping should be done with the patient in the Trendelenburg position.All patients must be examined at regular intervals after operation and injection of sclerosing material carried out as necessary.     

Complications of tonsillectomy and adenoidectomy in 9409 children observed overnight.

In attempts to minimize the cost of health care, physicians are reducing the duration of hospital stay. Traditionally, at the Hospital for Sick Children, Toronto, otherwise healthy children undergoing adenoidectomy, tonsillectomy or adenotonsillectomy have been admitted the morning of surgery and discharged from hospital at 7 am the next day. The nursing records of 9409 patients aged 17 years or less who were managed in this way between 1980 and 1984 were reviewed to determine the occurrence of complications during the observation period. A total of 202 patients (2.15%) bled during the observation period. Of the 202, 6 (0.06% of all the patients) required a second general anesthetic for hemostasis; 1 of these 6 patients and 5 others required blood transfusions. Discharge was delayed for 42 patients (0.45% of all the patients) because of postoperative bleeding and for 57 patients (0.6%) for a variety of other reasons. Delayed discharge for reasons other than hemorrhage was more frequent among children less than 2 years of age and those over 12 years of age. The authors concluded that children undergoing adenoidectomy could safely be discharged the same day after 6 hours of observation following surgery. However, as a substantial number of children bled from the tonsillar fossa more than 6 hours after surgery, the efficacy of periodic examination of the oral cavity during the observation period in reducing the rate of hemorrhage after 6 hours must be evaluated before a same-day discharge program is established for children undergoing adenotonsillectomy.     

Grommets,tonsillectomies, and deprivation in Scotland.

OBJECTIVE--To see whether there is a relation between grommet insertion operation and tonsillectomy rates, otolaryngology services, and deprivation scores in Scotland. DESIGN--Analysis of routine 1990 NHS data on grommet insertions and tonsillectomies in Scottish children aged 0-15 years compared with data on general practitioner and otolaryngology services and Carstairs deprivation scores. SETTING--All 15 Scottish health boards. SUBJECTS--All children aged 0-15 (1,021,933). RESULTS--Tonsillectomy was more common than grommet insertion operations in Scotland (6182:4850). Health boards with high grommet insertion rates were more likely to have low tonsillectomy rates (Spearman''s rank correlation -0.59; 95% confidence interval -0.87 to -0.03). Grommet insertion rates varied fourfold (from 2.4/1000 to 9.2/1000) and tonsillectomy rates twofold (from 3.6/1000 to 8.0/1000) across Scottish health boards. Variation between health boards had changed over the 15 years 1975-90. Variation in grommet insertion rates did not reflect variation in the supply of otolaryngology consultants (Spearman''s rank correlation -0.25). There was a non-significant tendency for high general practitioner referral rates to be associated with high grommet insertion rates, low tonsillectomy rates, and less deprived areas (Spearman''s rank correlation coefficients 0.50, -0.53, and -0.43). Deprivation (measured by Carstairs scoring for each health board) was associated with higher tonsillectomy rates (Spearman''s rank correlation 0.41; 95% confidence interval -0.22 to 0.80) and significantly lower grommet insertion rates (-0.73; -0.92 to -0.28). CONCLUSION--Social factors as well as differences in disease prevalence and medical practice need to be considered when studying variation in childhood grommet insertion and tonsillectomy rates.     

A Statistical Survey of Leukemia in Ontario and at the Ontario Cancer Foundation Clinics, 1938-1958

In Ontario, leukemia causes about 4% of all cancer deaths, ranging from nearly 50% at under 5 years of age to 1-3% at age 50 and over. Age-specific death rates are highest among older people; at all ages, male deaths exceed female deaths. Only about 20% of all leukemia patients in Ontario are registered at Ontario Cancer Clinics; the proportion changed sharply with the advent of chemotherapy. For 1258 patients registered in 1938-1963, the crude one-year survival rate was 50%, ranging from 9% for acute leukemia to about 60% for non-acute lymphatic and myeloid leukemia. The long-term outlook was much better for non-acute lymphatic leukemia than for non-acute myeloid leukemia. For acute leukemia, the treatment of choice was chemotherapy; for non-acute lymphatic leukemia, radiotherapy was used, followed, if required, by chemotherapy or further radiotherapy. For non-acute myeloid leukemia, the advantage of chemotherapy over radiotherapy was not established.     

Operations for hernia and varicose veins in a day-bed unit.

Over eight years (1970-8) 1055 patients underwent operations for hernia or "major" varicose veins in a day-bed unit. Here, 608 were discharged home on the day of operation, 262 were transferred to a convalescent hospital for 48 hours, and 161 were retained in the acute ward as part of a controlled trial. Special emphasis was placed on selection and preadmission screening. Failure of planning was uncommon in that only 2.5% were detained in hospital and 1% had to be readmitted. About one-quarter of the patients had complications but these were generally trivial and were satisfactorily treated by the community nursing sisters or general practitioners, or both. Analysis of the total operations for hernia or varicose veins in the unit over the past 19 years shows that, whereas formerly all patients with these conditions were admitted to the main surgical ward, nowadays almost all are managed either by day care or in a five-day ward.