Geoffrey R. Keyes

Mortality in outpatient surgery.

Background: The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) has reported statistics on morbidity and mortality for facilities that it accredits based on an analysis of unanticipated sequelae and surgical mortality. Data acquired through the first Internet-Based Quality Assurance and Peer Review reporting system (IBQAP) were reviewed and published in 2004. This article reports the accumulated data in the IBQAP through June of 2006, analyzing death associated with procedures performed in facilities approved by the AAAASF. With the exception of some statistics on the Medicare-aged population, there are few data reported in the literature related to deaths in outpatient surgery. Methods: The IBQAP, designed in 1999 by the AAAASF, mandates biannual reporting of all unanticipated sequelae and random case reviews by all surgeons operating in AAAASF–accredited facilities. Surgical log numbers, whose entry is required, allow for tabulation of the number of cases and procedures performed by individual reporting surgeons. Results: In this review of data collected using the IBQAP from January of 2001 through June of 2006, there were 23 deaths in 1,141,418 outpatient procedures performed. Pulmonary embolism caused 13 of the 23 deaths. Only one death occurred as the result of an intraoperative adverse event. Conclusions: A pulmonary embolism may occur after any operative procedure, whether it is performed in a hospital, an ambulatory surgery center, or a physician’s office-based surgery facility. The procedure most commonly associated with death from pulmonary embolism in an office-based surgery facility is abdominoplasty. The frequency of pulmonary embolism associated with abdominoplasty warrants further study to determine predisposing factors, understand its cause, and introduce guidelines to prevent its occurrence.

Parathyroid Microautotransplantation and the Viscerovertebral Angle

Conservation of physiologic values of circulating parathormone is a surgical objective in those instances in which a hyperfunctional parathyroid state exists as well as in those instances in which cervical evisceration employed as an ablative measure for the management of neoplastic disease threatens to impose postoperative tetany. Because the parathyroid glands may vary in number and in anatomic sites, a predictable and reproductible surgical approach that permits the operator an avenue of access to these structures is used. The viscerovertebral angle provides a surgical modality which facilitates the operative effort. The method has been applied in more than 70 patients.

Construction of a total extrathoracic neoesophagus with combined cutaneous and myoepithelial flaps

Restration of esophageal continuity between the cervical or thoracic esophagus and the upper gastrointestinal tract requires the interpolation of an epithelium-lined conduit which permits the unimpeded passage of saliva and food.

Total extrathoracic neoesophageal construction by combined cutaneous and myoepithelial flaps.

The combined use of skin-lined deltopectoral cutaneous and pectoralis major-serratus anterior myoepithelial flaps to construct a total extrathoracic neoesophagus provides the surgeon with an effective, low-morbidity technique, previously unreported, which may be employed as a method for, or as an adjunct to, enterocolonogastric replacement of the thoracic esophagus. The combined myoepitheliocutaneous flaps are surgically manuevered in a novel yet elementary method that culminates in the development of a total extrathoracic neoesophagus.

Surgical Palatomaxilloschisis: An Avenue to the Pterygomaxillary Space

The pterygomaxillary space (PMS) is a potential reservoir for expansion of the neoplasms originating in the epipharynx. Palatotomic and mandibulotomic approaches to this secluded site have been reported. The advantages of surgical palatomaxilloschisis are twofold. First, the exposure of the operative field is panoramic. Second, the carotid arterial system is identifiable prior to surgical intervention. The triangular pterygomaxillary recess is bounded superiorly by the greater wing of the sphenoid, posteriorly by the pterygoid process and anteriorly by the dorsal convexity of the posterior wall of the maxilla. Ascending laterally to the PMS in its route to penetrate the temporal bone is the internal carotid artery. In Particular, juvenile angiofibromas which originate in the epipharynx may in their growth encroach upon the bounds of the PMS. The surgical objective is not only to extirpate the neoplasm but also to safeguard the carotid arterial system which may be displaced by the new growth and thereby become a surgical hazard. A clinical experience illustrates the applicability of this approach.