RESUMEN
BACKGROUND: The quality of melanoma surgery needs to be assessed by oncological outcome and complication rates. There is no published consensus on complication rates for common melanoma surgeries, namely wide excision (WE), sentinel node biopsy (SNB) and regional lymph node dissection (RLND). Consequently there are no agreed standards by which surgeons can audit their practices. METHODS: Surgical standards were proposed in 2008 following review of the literature and from expert opinion. Melanoma Institute Australia (MIA) self-reported audit data from 2011 and 2012 were compared with these standards. To quality check the self-reported audit, RLND data were extracted from the MIA database. RESULTS: Six surgeons performed a mean of 568 surgeries each quarter; with a mean of 106 major procedures. Following WE with primary closure or flap repair, wound infection or dehiscence occurred in <1% of cases. When skin grafting was required non-take of >20% of the grafted area was observed in 5.9% of cases. Following SNB wound infection and significant seroma occurred in 1.8% of cases. RLND node counts were below the 90% standard in 4 of 409 procedures. In comparison, data extraction identified 405 RLNDs, with node counts below the 90% standard in eight procedures. Two of these patients had previously undergone surgery removing nodes from the field and two had gross coalescing disease with extensive extra-nodal spread. CONCLUSION: The quality standards proposed in 2008 have been validated long-term by high volume caseloads. The data presented provide standards by which melanoma surgeons can audit their surgical performance.
Asunto(s)
Escisión del Ganglio Linfático , Ganglios Linfáticos/patología , Ganglios Linfáticos/cirugía , Melanoma/cirugía , Garantía de la Calidad de Atención de Salud , Biopsia del Ganglio Linfático Centinela , Neoplasias Cutáneas/cirugía , Adulto , Anciano , Australia , Supervivencia sin Enfermedad , Femenino , Humanos , Metástasis Linfática/diagnóstico , Masculino , Auditoría Médica , Melanoma/mortalidad , Melanoma/secundario , Persona de Mediana Edad , Calidad de Vida , Neoplasias Cutáneas/mortalidad , Neoplasias Cutáneas/patología , Análisis de Supervivencia , Centros de Atención TerciariaRESUMEN
A comprehensive surgical and therapy program for the management of carpal tunnel neuropathy caused by injury has been proposed. The program is based on the restoration of the gliding interface between the median nerve trunk, the flexor tendons of the fingers, and the inner gliding surface of the transverse carpal ligament. The development of these new gliding surfaces is achieved by a surgery program of circumferential mesoepineurolysis of the median nerve in the hand and wrist followed by an anatomic reconstruction of the transverse carpal ligament. This biologic process is completed by a postoperative program of immediate hand function and median nerve gliding. Three hundred consecutive surgical patients were studied to confirm that the elastic mobilization of the median nerve actually doubled after a comprehensive nerve mobilization, thus supporting the ligament closure and early nerve gliding. Patients who have been available for repeat electromyographic (EMG) study at four to six months show EMG improvement that supports the clinical improvement. Finally, mobilization of the median nerve as described in the study has shown nerve revascularization within 30 seconds after tourniquet release and biologic recovery signals in the postoperative nerve gliding period and has proven to be, from the nerve nutrition standpoint, a safe procedure. The reliability that has been achieved in median nerve recovery is due to the anatomic reconstruction of the entire transverse carpal ligament. This surgical technique has proven to be the step necessary to produce a symbiotic alignment of the median nerve and the flexor tendon gliding anatomy.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Plexo Braquial/lesiones , Síndrome del Túnel Carpiano/cirugía , Adulto , Síndrome del Túnel Carpiano/etiología , Síndrome del Túnel Carpiano/rehabilitación , Electromiografía , Humanos , Ligamentos Articulares/cirugía , Masculino , Nervio Mediano/cirugía , Examen Neurológico/métodos , Complicaciones Posoperatorias/etiología , Sensación , Procedimientos Quirúrgicos Operativos/métodosRESUMEN
Peripheral nerve compression syndromes most often produce neuropathic changes that are recordable by conventional electrophysiologic testing techniques. Occasionally, a patient exhibits all the appropriate clinical signs, symptoms, and history of a compartment syndrome, such as a carpal tunnel syndrome, but electrophysiologic testing procedures will be normal, thus seeming to identify no neuropathic component to the syndrome. Researchers have reasonably concluded that wrist position or hand activity can have an adverse affect on intracompartmental carpal pressures, with resultant ischemic changes in epineural blood supply and subsequent compromise in nerve conduction parameters during and for a short time after the ischemic event. The stress testing protocol presented here identifies such changes, which would otherwise go undetected or undocumented and which may lead to unsuccessful clinical decisions regarding management. Sample tracings of actual cases are presented to demonstrate actual changes produced by the use of the protocol. This test protocol is used only when conventional testing is normal in the presence of appropriate clinical symptomatology.