Substantiation of organ-preserving surgical treatment of children with nonparasitic spleen cysts

BACKGROUND: The urgency of surgical treatment of children with nonparasitic spleen cysts is determined by the lack of consensus in the professional community, lack of regulatory documents governing the treatment of these patients, frequency of postoperative complications, and unfavorable outcomes. AIM: This study aimed to improve the efficiency and safety of organ-preserving minimally invasive interventions in children with nonparasitic spleen cysts based on the development of a multifactorial preoperative planning system and substantiation of an algorithm for choosing the optimal surgical strategies. MATERIALS AND METHODS: Results of surgical treatment of 60 children aged 218 yrs with nonparasitic spleen cysts are presented. The spleen cyst volume varied from 3 ml to 1000 ml (Me 50 ml). Preoperative examination included clinical examination, laboratory diagnostics, ultrasonography, computed tomography or magnetic resonance imaging, and angiography of the spleen vessels. The range of surgical technologies included percutaneous puncture (n = 2) and percutaneous puncture drainage (n = 28), followed by sclerosing of the cyst with 96% ethyl alcohol, combined interventions, supplemented by superselective embolization of the spleen arteries feeding the pathological formation (n = 15), laparoscopic fenestrations of cysts with physical de-epithelialization of the inner lining (n = 14), and laparoscopic resection of the spleen pole (n = 1). RESULTS: The analysis of postoperative complications was carried out depending on the chosen technology of surgical treatment. The follow-up period of 44 patients varied from 6 mon to 3 yrs, which made it possible to reveal the regularities of the reduction of residual cyst cavities and the course of the regeneration processes with an objective assessment of the volumetric characteristics of the spleen. Obliteration of the residual cyst cavities was observed in 79.1% of the patients during the first month after surgery. Subsequent total obliteration of the residual cyst cavities was observed within 1 yr after surgery in 91.7% of children and residual pathological formations persisted in five patients, which accounted for 8.3% of clinical observations. The volume of residual cysts ranged from 1.2% to 10.0% of the initial value, which was regarded as a satisfactory treatment result. CONCLUSION: Results of a retrospective multivariate analysis made it possible to develop an algorithm for substantiating surgical techniques, providing a radical cure for 95.5% of children with nonparasitic spleen cysts.

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Outcomes Following Surgical Treatment of Hallux Valgus Deformity

Foot & Ankle Orthopaedics ◽

10.1177/2473011417s000110 ◽

2017 ◽

Vol 2 (3) ◽

pp. 2473011417S0001

Author(s):

Alexej Barg ◽

Charles Saltzman

Keyword(s):

Surgical Treatment ◽

Postoperative Complications ◽

Hallux Valgus ◽

Surgical Techniques ◽

Weighted Average ◽

Secondary Surgery ◽

Weighting Method ◽

Hallux Varus ◽

Hallux Valgus Deformity ◽

Inverse Variance

Category: Bunion Introduction/Purpose: Hallux valgus (HV) deformity is one of the most common chronic disorders. Surgical correction plays a central role in the treatment of painful HV deformity with over 100 different surgical techniques described in the current literature. In this report we performed a systematic literature review on studies that addressed clinical outcomes following surgical treatment of hallux valgus. The objectives of our study were to (1) describe available study characteristics on surgical HV deformity treatment; (2) determine patients’ postoperative satisfaction including postoperative pain and recurrence of HV deformity; (3) determine rate of postoperative complications by surgery type; and (4) analyze the relationship between radiographic HV deformity parameters and postoperative complication rate. Methods: We reviewed the literature using common data bases. All searches were unlimited. Study demographics were collected and analyzed. Gender distribution was estimated using an inverse-variance weighting method and patient age and follow-up time were summarized using a simple weighted average due to an absence of reporting variance in the majority of studies. A chi- squared Q test, or heterogeneity test, was used to test for differences across surgery types for patient dissatisfaction, deformity recurrence, removal of hardware, reoperation, nonunion, hallux varus, nerve injury, infection, metatarsalgia, and VAS>5. Outcome estimates and 95% confidence intervals (CIs) for each surgery type were pooled across studies using the inverse-variance weighting method. A random effects model was used when study variance was estimated using the DerSimonian-Laird method. Results: In total, 269 studies with 13,112 patients and 16,594 feet were included. Patients treated by simple buniectomy had the highest dissatisfaction rate with 25.5% (95%CI 17.5-35.6). Deformity recurrence was highest in patients treated by proximal osteotomy with 10.5% (95%CI 5.6-18.7). The highest rate of secondary surgery was in patients treated by simple buniectomy with 6.1% (95%CI 2.4-14.7). In the same patient group the highest rate of hallux varus deformity was observed with 9.1% (95%CI 2.9- 24.9). Patients treated by hemi-joint resection had the highest rate of postoperative metatarsalgia with 16.2% (95%CI 11.3-22.8) and persisting pain VAS>5 with 6.5% (95%CI 3.3-12.3). Conclusion: Patients with buniectomy and hemi-joint resection demonstrated the highest rates of postoperative complications including dissatisfaction, need for secondary surgery, postoperative metatarsalgia, and persisting pain.

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Pneumonectomy in the treatment of tuberculosis relapse in a previously resected lung

Grekov s Bulletin of Surgery ◽

10.24884/0042-4625-2020-179-2-11-19 ◽

2020 ◽

Vol 179 (2) ◽

pp. 11-19

Author(s):

D. B. Giller ◽

A. A. Glotov ◽

O. Sh. Kesaev ◽

E. M. Glotov ◽

Ya. G. Imagogev ◽

...

Keyword(s):

Surgical Treatment ◽

Postoperative Complications ◽

Clinical Effect ◽

High Efficiency ◽

Radical Surgery ◽

Surgical Techniques ◽

Results Of Treatment ◽

Completion Pneumonectomy ◽

Medical Indications ◽

Tuberculosis Relapse

THE OBJECTIVE of our study was to increase the efficiency of treatment of tuberculosis postoperative reactivations in a previously operated lung, by clarifying the medical indications, improving surgical techniques and tactics when removing a previously resected lung.METHODS AND MATERIALS. We analyzed the results of treatment of 220 patients who, in the 2004–2017 timeframe in our institution, had pneumonectomies (76 cases) and pleuropneumonectomies (144 cases) for tuberculosis relapse in a previously operated lung. For more objective planning of surgical treatment and evaluation of its results, we identified three degrees of treatment radicalism: radical, conditionally radical, and palliative.RESULTS. 32 patients, who had carried a radical surgery, were diagnosed as having a complete clinical effect at the time of discharge (absence of destruction cavities in a single lung, bacterial excretion and illiquid complications) in 100 % of cases; in the group of patients operated conditionally radical, there were diagnosed 161 out of 168 (95.8 %) and in the group of patients operated palliative, there were distinguished only 3 cases out of 20 (15.0 %).CONCLUSION. The implementation of the completion pneumonectomy and pleurapneumonectomy is accompanied by high technical complexity and more frequent development of intraoperative and postoperative complications. At the same time, the high efficiency of treatment of tuberculosis relapses in a previously operated lung can be achieved using the recommended tactics and techniques of surgical treatment when performing radical and conditionally radical interventions.

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Surgical treatment of liver echinococcosis

Perm Medical Journal ◽

10.17816/pmj38332-40 ◽

2021 ◽

Vol 38 (3) ◽

pp. 32-40

Author(s):

M. F. Zarivchatskiy ◽

I. N. Mugatarov ◽

E. D. Kamenskikh ◽

M. V. Kolyvanova ◽

N. S. Teplykh

Keyword(s):

Surgical Treatment ◽

Liver Resection ◽

Postoperative Complications ◽

Hospital Stay ◽

Average Length ◽

Enzyme Linked Immunosorbent Assay ◽

Percutaneous Puncture ◽

Echinococcal Cyst ◽

Duration Of Surgery ◽

Methods Of Treatment

Objective. To improve the results of treatment of patients with liver echinococcosis and carry out a comparative assessment of techniques of surgical treatment depending on the nature of postoperative complications, hospital stay and antirecurrent efficacy. Materials and methods. The experience of complex examination and treatment of 65 patients with liver echinococcosis for the period of 1999-2019 was analyzed. Open echinococectomy was performed in 21 patients, atypical liver resection in 18 patients, anatomical liver resection in 14 patients, pericystectomy in 10, laparoscopic echinococectomy in 1, percutaneous puncture of an echinococcal cyst under ultrasound control in 1 patient. Results. The time of inpatient treatment of patients after open echinococectomy was 23.5 4.3 days, after pericystectomy 19.8 1.4 days, after liver resection 14.4 2.7 days, after laparoscopic echinococcectomy 6, after percutaneous puncture echinococcal cyst 7 days. Postoperative complications were observed in 52.4 % of patients who underwent open echinococectomy, in 20 % of patients after pericystectomy, and in 15.6 % after liver resection. There were no relapses of liver echinococcosis in all the groups. Mortality was 1.5 % and was recorded after open echinococectomy. Conclusions. The most effective techniques for preventing postoperative complications are pericystectomy and liver resection. The duration of surgery and the average length of hospital stay with minimally invasive methods of treatment are shorter. However, the use of these methods of treatment remains controversial due to the possibility of intra-abdominal spread of the parasite. Patients with parasitic liver cysts after surgical treatment are subjected to dynamic follow-up observation (ultrasound examination of the liver, enzyme-linked immunosorbent assay, computed tomography of the abdominal organs) after 3-6 months for at least 5 years.

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Morbidity and mortality of pancreatic tumors undergoing surgical treatment

ABCD Arquivos Brasileiros de Cirurgia Digestiva (São Paulo) ◽

10.1590/s0102-67202014000400011 ◽

2014 ◽

Vol 27 (4) ◽

pp. 275-279 ◽

Cited By ~ 8

Author(s):

Luiza Bueno ZENI ◽

Ricardo Fantazzini RUSSI ◽

Alexandre Faleiro FIALHO ◽

Ana Luiza Pagani FONSECA ◽

Lyara Schaefer SOMBRIO ◽

...

Keyword(s):

Pancreatic Cancer ◽

Surgical Treatment ◽

Postoperative Complications ◽

Medical Records ◽

Malignant Tumors ◽

Surgical Techniques ◽

Pancreatic Head ◽

Ductal Adenocarcinoma ◽

Pancreatic Tumors ◽

Early Postoperative Complications

BACKGROUND: Pancreatic cancer has a high mortality rate due to late diagnosis and aggressive behavior. The prognosis is poor, with 5-year survival occurring in less than 5% of cases. AIM: To analyze demographic characteristics, comorbidities, type of procedure and early postoperative complications of patients with pancreatic cancer submitted to surgical treatment. METHODS: Cross-sectional study with analysis of 28 medical records of patients with malignant tumors of the pancreas in a 62 month. Data collection was performed from the medical records of the hospital. RESULTS: Of the total, 53,6% were male and the mean age was 60.25 years. According to the procedure, 53,6% was submitted to duodenopancreactectomy the remainder to biliodigestive derivation or distal pancreatectomy. The ductal adenocarcinoma occurred in 82,1% and 92,9% of tumors were located in the pancreatic head. Early postoperative complications occurred in 64,3% of cases and the most prevalent was intra-abdominal abscess (32,1%). Among duodenopancreactectomies 77,8% had early postoperative complications. CONCLUSION: Its necessary to encourage early detection of tumors of the pancreas to raise the number operations with curative intent. Refinements in surgical techniques and surgical teams can diminish postoperative complications and, so, operative morbimortality can also decrease over time.

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Results of treatment of congenital clubfoot after soft tissue release in children

Paediatric Surgery Ukraine ◽

10.15574/ps.2020.69.81 ◽

2020 ◽

pp. 81-85

Author(s):

O. Holubenko ◽

◽

A. Levytskyi ◽

O. Karabenyuk ◽

◽

...

Keyword(s):

Surgical Treatment ◽

Postoperative Complications ◽

Surgical Techniques ◽

Term Treatment ◽

Soft Tissue Release ◽

Idiopathic Clubfoot ◽

Congenital Clubfoot ◽

Cuboid Bone ◽

Long Term Treatment ◽

Plaster Casts

Topicality. Widespread use of the method of I. Ponseti allows to significantly reduce the number of reconstructive surgeries and/or reduce their volume. However, if presence the rigid, severe deformities that cannot be corrected with staged plaster casts, or recurrences, surgical treatment is advisable. The literature describes many surgical techniques, the main purpose of which is to reduce the frequency of postoperative complications. And at the same time find the most convenient access to eliminate contractures, further wound healing by primary tension with minimal formation of connective tissue elements. Objective: to reduce the incidences of complications in the surgical treatment of congenital clubfoot by using a modified surgical approach. Materials and methods. In the Department of Orthopedics and Traumatology of NCSH «OKHMATDYT» 57 children (72 feet) with a diagnosis of congenital clubfoot underwent surgical treatment using a modified Carroll approach for the period from January 2014 to September 2018. The mean age of patients was 3±0.4 years. 41 of them boys and 16 girls. Bilateral deformity was observed in 12 patients. 48 patients (58 feet) were underwent surgical treatment after initial treatment with staged plaster casts according to the method of I. Ponseti. Recurrences of deformity after surgery was observed in 9 patients (14 feet). Results. When assessing the immediate results during surgery in all patients, complete correction of foot deformity was achieved. No postoperative complications were noted. Long-term treatment results 2 years after surgery showed that good results were in 12 patients (21±9.53%), satisfactory in 39 (68.4±27.14%) and unsatisfactory in 6 (7±2.18%). Four patients with unsatisfactory results and residual manifestations of deformity in the form of passively corrected isolated adduction of the anterior foot, subsequently underwent surgery to transplant the anterior tibialis tendon to the lateral cuneiform bone. And 2 patients – wedge-shaped resection of the cuboid bone. Indication of which was not the possibility of passive correction of deformity. Conclusions. The comparative analysis of the obtained results and literature data testifies to the effectiveness of the proposed method of treatment of idiopathic clubfoot in children (using three approaches), as well as in the presence of residual deformity after conservative and surgical treatment. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of participating institution. The informed consent of the patient was obtained for conducting the studies. Key words: clubfoot, children, posteromedial release, surgical treatment.

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Temporary “liquid” Implant for Congenital Glaucoma (long-term results)

International scientific-practical journal Ophthalmology ◽

10.30702/ophthalmology30092020-11.1.2049-65 ◽

2020 ◽

pp. 49-65

Author(s):

N Bobrova ◽

N Trofimova

Keyword(s):

Surgical Treatment ◽

Postoperative Complications ◽

Hypotensive Effect ◽

Congenital Glaucoma ◽

Long Term Results ◽

General Will ◽

Visual Functions ◽

Advanced Stages ◽

Intraocular Fluid

The aim of the work was to analyze the long-term results of using a temporary “liquid” implant in the surgery of congenital glaucoma in children. The basis of the developed method of filtrative antiglaucomatous surgery (Patent of Ukraine No. 45099 of 2009) – viscosinusotrabeculotomy – has been set the task of reducing the risk of developing intra- and postoperative complications, reducing the scarring rate and maintaining the newly created ways of the intraocular ﬂuid outﬂow, which in general will increase the effectiveness of surgical treatment of congenital glaucoma in children. 54 children (91 eyes) with simple congenital glaucoma at the age of 1 to 36 months were operated on average (8.7 ± 8.2) months. The persistent and long-lasting hypotensive effect achieved due to viscosinusotrabeculotomy in children with developed and far-advanced stages of congenital glaucoma stops the processes of stretching of the membranes of the eye and stabilizes their size, which in general allows preserving and visual functions improving, in infancy – creating conditions for their formation.

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FEATURES OF OPHTHALMIC CARE FOR PATIENTS WITH COMPLICATED CATARACTS

International Medical Journal ◽

10.37436/2308-5274-2019-4-18 ◽

2020 ◽

pp. 84-89

Author(s):

Inna Ivanovna Lapkina

Keyword(s):

Health Care ◽

Surgical Treatment ◽

Postoperative Complications ◽

Key Words ◽

Outpatient Treatment ◽

Practical Application ◽

Unified Approach ◽

Case Histories ◽

High Prevalence

Today, around 50 million people worldwide suffer from cataracts, more than a half of them need surgical treatment. High prevalence of this pathology in Ukraine, the need to improve the provision of ophthalmic care to patients, and the reform of the health care system have made the research relevant. Concomitant diseases and special conditions of the eye increase the risk of intra− and postoperative complications, worsen the functional parameters of patients after surgery. In order to develop a unified approach to the treatment of complicated cataracts based on diagnostically related groups of patients, a retrospective analysis of case histories of patients with different variants of complications related to the condition of the lens itself, its ligament apparatus and other structures of the eye was conducted. In each case, the surgeon has to choose the appropriate modification of cataract phacoemulsification surgery. The study proposed the classification of cataract phacoemulsification modifications on the basis of the techniques and the sequence of operation stages, taking into account the classification of the degrees of turbidity of the lens, proposed by L. Buratto. It has been noted that in complicated cases, according to the indications of the patient, surgery may be performed on several modifications of cataract phacoemulsification. The developed classification made it possible to generalize the various variants of pathology and greatly facilitate the choice of tactics of surgical treatment in complicated cataracts. It can be used not only for practical application, but also for improving the qualification of trained professionals. The prospect of further research is to identify contraindications for outpatient treatment of the patients with complicated cataracts. Key words: cataract complication, classification of phacoemulsification modifications, diagnostically related groups.

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PREDICTIVE FACTORS IN THE CHOICE OF SURGICAL TREATMENT FOR COLORECTAL CANCER WITH LAPAROSCOPIC OR "OPEN" ACCESS

Problems in oncology ◽

10.37469/0507-3758-2017-63-3-470-474 ◽

2017 ◽

Vol 63 (3) ◽

pp. 470-474

Author(s):

Rustem Topuzov ◽

Georgiy Manikhas ◽

Eskender Topuzov ◽

Mikhail Khanevich ◽

Magomed Abdulaev ◽

...

Keyword(s):

Colorectal Cancer ◽

Surgical Treatment ◽

Postoperative Complications ◽

Open Access ◽

Comparative Study ◽

Retrospective Analysis ◽

Predictive Factors

There are presented results of surgical treatment of 347 patients with colorectal cancer. Based on the retrospective analysis a comparative study of results of surgical treatment for colorectal cancer using laparoscopic technologies and “open” access was carried out. Predictive factors that correlate with the risk of postoperative complications with laparoscopic and “open” access at the surgical stage of treatment for colorectal cancer were determined.

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Long-Term Clinical Outcomes of Osteochondritis Dissecans Lesions of the Elbow Treated with Arthroscopy

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967121s00202 ◽

2021 ◽

Vol 9 (7_suppl4) ◽

pp. 2325967121S0020

Author(s):

Michael Ryan ◽

Benton Emblom ◽

E. Lyle Cain ◽

Jeffrey Dugas ◽

Marcus Rothermich

Keyword(s):

Surgical Treatment ◽

Clinical Outcomes ◽

Failure Rate ◽

Osteochondritis Dissecans ◽

Surgical Techniques ◽

The Other ◽

Return To Play ◽

Exclusion Criteria

Objectives: While numerous studies exist evaluating the short-term clinical outcomes for patients who underwent arthroscopy for osteochondritis dissecans (OCD) of the capitellum, literature on long-term clinical outcomes for a relatively high number of this subset of patients from a single institution is limited. We performed a retrospective analysis on all patients treated surgically for OCD of the capitellum at our institution from January 2001 to August 2018. Our hypothesis was that clinical outcomes for patients treated arthroscopically for OCD of the capitellum would be favorable, with improved subjective pain scores and acceptable return to play for these patients. Methods: Inclusion criteria for this study included the diagnosis and surgical treatment of OCD of the capitellum treated arthroscopically with greater than 2-year follow-up. Exclusion criteria included any surgical treatment on the ipsilateral elbow prior to the first elbow arthroscopy for OCD at our institution, a missing operative report, and/or any portions of the arthroscopic procedure that were done open. Follow-up was achieved over the phone by a single author using three questionnaires: American Shoulder and Elbow Surgeons – Elbow (ASES-E), Andrews/Carson KJOC, and our institution-specific return-to-play questionnaire. Results: After the inclusion and exclusion criteria were applied to our surgical database, our institution identified 101 patients eligible for this study. Of these patients, 3 were then excluded for incomplete operative reports, leaving 98 patients. Of those 98 patients, 81 were successfully contacted over the phone for an 82.7% follow-up rate. The average age for this group at arthroscopy was 15.2 years old and average post-operative time at follow-up was 8.2 years. Of the 81 patients, 74 had abrasion chondroplasty of the capitellar OCD lesion (91.4%) while the other 7 had minor debridement (8.6%). Of the 74 abrasion chondroplasties, 29 of those had microfracture, (39.2% of that subgroup and 35.8% of the entire inclusion group). Of the microfracture group, 4 also had an intraarticular, iliac crest, mesenchymal stem-cell injection into the elbow (13.7% of capitellar microfractures, 5.4% of abrasion chondroplasties, and 4.9% of the inclusion group overall). Additional arthroscopic procedures included osteophyte debridement, minor synovectomies, capsular releases, manipulation under anesthesia, and plica excisions. Nine patients had subsequent revision arthroscopy (11.1% failure rate, 5 of which were at our institution and 4 of which were elsewhere). There were also 3 patients within the inclusion group that had ulnar collateral ligament reconstruction/repair (3.7%, 1 of which was done at our institution and the other 2 elsewhere). Lastly, 3 patients had shoulder operations on the ipsilateral extremity (3.7%, 1 operation done at our institution and the other 2 elsewhere). To control for confounding variables, scores for the questionnaires were assessed only for patients with no other surgeries on the operative arm following arthroscopy (66 patients). This group had an adjusted average follow-up of 7.9 years. For the ASES-E questionnaire, the difference between the average of the ASES-E function scores for the right and the left was 0.87 out of a maximum of 36. ASES-E pain was an average of 2.37 out of a max pain scale of 50 and surgical satisfaction was an average of 9.5 out of 10. The average Andrews/Carson score out of a 100 was 91.5 and the average KJOC score was 90.5 out of 100. Additionally, out of the 64 patients evaluated who played sports at the time of their arthroscopy, 3 ceased athletic participation due to limitations of the elbow. Conclusions: In conclusion, this study demonstrated an excellent return-to-play rate and comparable subjective long-term questionnaire scores with a 11.1% failure rate following arthroscopy for OCD of the capitellum. Further statistical analysis is needed for additional comparisons, including return-to-play between different sports, outcome comparisons between different surgical techniques performed during the arthroscopies, and to what degree the size of the lesion, number of loose bodies removed or other associated comorbidities can influence long-term clinical outcomes.

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Outcomes of Surgical and Nonsurgical Treatment for Colorectal Cancer in Nonagenarian Patients

The American Surgeon ◽

10.1177/0003134821995060 ◽

2021 ◽

pp. 000313482199506

Author(s):

Youngbae Jeon ◽

Kyoung-Won Han ◽

Won-Suk Lee ◽

Jeong-Heum Baek

Keyword(s):

Colorectal Cancer ◽

Overall Survival ◽

Surgical Treatment ◽

Postoperative Complications ◽

Postoperative Mortality ◽

Nonsurgical Treatment ◽

Perioperative Outcomes ◽

Rank Test ◽

Kaplan Meier ◽

Number Of Patients

Purpose This study is aimed to evaluate the clinical outcomes of surgical treatment for nonagenarian patients with colorectal cancer. Methods This retrospective single-center study included patients diagnosed with colorectal cancer at the age of ≥90 years between 2004 and 2018. Patient demographics were compared between the operation and nonoperation groups (NOG). Perioperative outcomes, histopathological outcomes, and postoperative complications were evaluated. Overall survival was analyzed using Kaplan-Meier methods and log-rank test. Results A total of 31 patients were included (16 men and 15 women), and the median age was 91 (range: 90‐96) years. The number of patients who underwent surgery and who received nonoperative management was 20 and 11, respectively. No statistical differences in baseline demographics were observed between both groups. None of these patients were treated with perioperative chemotherapy or radiotherapy. Surgery comprised 18 (90.0%) colectomies and 2 (10.0%) transanal excisions. Short-term (≤30 days) and long-term (31‐90 days) postoperative complications occurred in 7 (35.0%) and 4 (20.0%) patients, respectively. No complications needed reoperation, such as anastomosis leakage or bleeding. No postoperative mortality occurred within 30 days: 90-day postoperative mortality occurred in two patients (10.0%), respectively. The median overall survival of the operation group was 31.6 (95% confidence interval: 26.7‐36.5) and that of NOG was 12.5 months (95% CI: 2.4‐22.6) ( P = 0.012). Conclusion Surgical treatment can be considered in carefully selected nonagenarian patients with colorectal cancer in terms of acceptable postoperative morbidity, with better overall survival than the nonsurgical treatment.

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