The Pediatric Laparoscopic Surgery (PLS) simulator: Methodology and results of further validation

Background

The Pediatric Laparoscopic Surgery (PLS) simulator is the only validated tool for pediatric Minimal Access Surgery. Construct validity (the ability to discriminate between novice, intermediate and expert) for the PLS simulator had previously been established on the basis of the total PLS score, as well as the individual performance on three of the five tasks. We describe the process and methods used to establish independent construct validity for a fourth task: pattern-cutting.

Methods

After considering various options for the possible modifications of the task itself, we retrospectively altered the way the pattern-cutting task was scored by modifying the weighting of precision versus time without changing the task itself. This was subsequently tested prospectively at the 2011 Canadian Association of Pediatric Surgeons meeting.

Results

Modification in the scoring metrics allowed differentiation within a previously tested cohort of 84 candidates (20 novices: score = 48 ± 16, 19 intermediates: score = 59 ± 18, 45 experts: score = 69 ± 12 p = 0.01). This was validated prospectively in a cohort of 18 experts and 7 intermediates (65 ± 8, 54 ± 17 p = 0.03).

Conclusions

Construct validity for the pattern-cutting task was established by modification of the scoring metrics. This was validated both retrospectively and prospectively.     

Validation of measures from a thoracoscopic esophageal atresia/tracheoesophageal fistula repair simulator

Purpose

A validated high fidelity simulation model would provide a safe environment to teach thoracoscopic EA/TEF repair to novices. The study purpose was to evaluate validity evidence for performance measures on an EA/TEF simulator.

Methods

IRB-exempt data were collected from 12 self-reported “novice” and 8 “experienced” pediatric surgeons. Participants evaluated the EA/TEF repair simulator using survey ratings that were analyzed for test content validity evidence. Additionally, deidentified operative performances were videotaped and independently rated by two surgeons using the Objective Structured Assessment for Technical Skills (OSATS) instrument. Novice and experienced OSATS were compared with p < .05 significant.

Results

Participants had high overall simulator ratings. Internal structure was supported by high interitem consistency (α = .95 and .96) and interrater agreement (ICC) [.52, .84] for OSATS ratings. Experienced surgeons performed at a significantly higher level than novices for all five primary and two supplemental OSATS items (p < .05).

Conclusion

Favorable participant ratings indicate the simulator is relevant to clinical practice and valuable as a learning tool. Further, performance ratings can discriminate experienced and novice performances of EA/TEF repair. These findings support the use of the simulator for performance assessment, representing the first validated measures from a simulator intended for pediatric surgical training.     

Refinement in the analysis of motion within low-cost laparoscopic simulators of differing size: Implications on assessing technical skills

Background

Simulation is becoming more important in the teaching and assessment of technical skills. The purpose of this study was to refine the use of motion analysis parameters (MAPs) to assess performance of a defined task in low-cost pediatric laparoscopic simulators of differing size.

Utilisation d’un fibroscope à usage unique pour la formation sur labyrinthe à l’intubation sous fibroscope

Goal of the study

To evaluate a single-use fiberscope, the Ascope-Trainer™, for the training in the intubation under fiberscope.

Type of study

Prospective randomized study approved by the local ethic committee.

Methodology

After evaluation of their level of expertise, “experienced” or “novices” in intubation under fiberscope, the doctors attending the Training for Referents in Difficult Airway Management performed a test on labyrinth with a standard fiberscope (T1). After they were assigned to two groups, training with the Ascope-Trainer™ (group A, n = 35) or with a classic fiberscope (group C, n = 29), they trained during 15 minutes and performed a new test (T2). An analysis of variance was used to compare means. A goal for the training was determined according to the “experienced” doctors’ mean T1. A test of Khi² was used for the comparison of the number of participants having reached this goal as well as the progress in both groups A and C.

Results

The T1 in the “experienced” group was 76 ± 31 s and the training improved significantly T2 (53 ± 17 s). Considering the novices, T2 was significantly lower than T1 in the group A (77 ± 38 s versus 135 ± 68 s) as well as in C (64 ± 28 s versus 122 ± 60 s), and the proportion of the novices having reached the goal of training was comparable in both groups.

Conclusions

Because its use is similar to the standard fiberscope, the Ascope-Trainer™ may be interesting for this type of training.     

Comparison of outcomes after triceps split versus sparing surgery for extra-articular distal humerus fractures

Objectives

To compare elbow range of motion (ROM), triceps extension strength, and functional outcome of AO/OTA type A distal humerus fractures treated with a triceps-split or -sparing approach.

Design

Retrospective review.

Setting

Two level one trauma centres.

Patients

Sixty adult distal humerus fractures (AO/OTA 13A2, 13A3) presenting between 2008 and 2012 were reviewed. Exclusion criteria removed 18 total patients from analysis and three patients died before final follow-up.

Intervention

Patients were divided into two surgical approach groups chosen by the treating surgeon: triceps split (16 patients) or triceps sparing (23 patients).

Main outcome measurements

Elbow ROM and triceps extension strength testing were completed in patients after fractures had healed. All patients were also given the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.

Results

Compared to the triceps-split cohort, the triceps-sparing cohort had greater elbow flexion (sparing 143 ± 7° compared to split 130 ± 12°, p = 0.03) and less extension contracture (sparing 6 ± 8° compared to split 23 ± 4°, p < 0.0001). Triceps strength compared to the uninjured arm also favoured the triceps-sparing cohort (sparing 88.9 ± 28.3% compared to split 49.4 ± 17.0%, p = 0.007). DASH scores were not statistically significant between the two cohorts (sparing 14.5 ± 12.2 compared to split 23.6 ± 22.3, p = 0.333).

Conclusions

A triceps-sparing approach for surgical treatment of extra-articular distal humerus fractures can result in better elbow ROM and triceps strength than a triceps-splitting approach. Both approaches, however, result in reliable union and similar functional outcome.

Level of evidence

Level III.     

Analysis of hand motion differentiates expert and novice surgeons

Background

The number of operations performed by a surgeon may be an indicator of surgical skill. The hand motions made by a surgeon also reflect skill and level of expertise. We hypothesized that the hand motions of expert and novice surgeons differ significantly, regardless of whether they are familiar with specific tasks during an operation.

Methods

This study compared 11 expert surgeons, each of whom had performed >100 laparoscopic procedures, and 27 young surgeons, each of whom had performed <15 laparoscopic procedures. Each examinee performed a specific skill assessment task, in which instrument motion was monitored using magnetic tracking system. We analyzed the paths of the centers of gravity of the tips of the needle holders and the relative paths of the tips using two mathematical methods of detrended fluctuation analysis and unstable periodic orbit analysis.

Results

Detrended fluctuation analysis showed that the exponent in the function describing the initial scaling exponent (α₁) differed significantly for experts and novices, being close to 1.0 and 1.5, respectively (P < 0.01). This indicated that the expert group had a greater long-range coherence with an intrinsic sequence and smooth continuity among a series of motions. Likewise, unstable periodic orbit analysis showed that the second period of unstable orbit was significantly longer for experts in comparison with novices (P < 0.01). This demonstrates mathematically that the hands of experts are more stable when performing laparoscopic procedures.

Conclusions

Objective evaluation of hand motion during a simulated laparoscopic procedure showed a significant difference between experts and novices.     

Laparoscopic Approach for Artificial Urinary Sphincter Implantation in Women with Intrinsic Sphincter Deficiency Incontinence: A Single-Centre Preliminary Experience

Background

Implantation of an artificial urinary sphincter (AUS) is used as a last resort in women with stress urinary incontinence (SUI).

Objective

To assess the early functional outcome after laparoscopic placement of an AUS in women.

Design, setting, and participants

Twelve women with type 3 SUI underwent a laparoscopic AUS placement between 2006 and 2008. Eleven (92%) had previously undergone anti-incontinence procedures.

Intervention

The AUS was implanted with laparoscopic access either preperitoneally or intraperitoneally. The cuff was placed around the bladder neck between the periurethral fascia and the vagina.

Measurements

Perioperative complications were reviewed. To assess resolution of urinary incontinence, all patients were seen at 1, 3, 6, and 12 mo after the surgery and yearly thereafter.

Results and limitations

The mean age of subjects was 56.7 ± 12 yr (33–78). The mean body mass index was 24 ± 2.3 (20–25). The mean preoperative closure pressure was 22 ± 10.9 cmH₂O (4–35). The mean operative time was 181 ± 39 min [110–240]. Intraoperative complications occurred in three women (25%), with bladder (n = 2) and vaginal (n = 2) injuries. These complications required open conversion. AUS implantation was postponed in one case. The mean hospital stay was 7 ± 2.3 d (3–11). The bladder catheter was removed after a mean time of 10 ± 8 d (2–30). Urinary retention was observed in five cases (45%) after bladder catheter removal. AUS activation was done 4–14 wk after implantation. Mean follow-up was 12.1 ± 8 mo (5.2–27). Incontinence was completely resolved in eight women (88%) who underwent complete laparoscopic procedure. The main limitation of the study was the limited length of follow-up.

Conclusions

AUS implantation can be successfully achieved by laparoscopy. It appears to be technically feasible. These results are still preliminary, and further studies of larger populations with longer follow-up are needed to make any statement regarding surgical strategy.     

Effect of isokinetic training on muscle strength,size and gait after healed pediatric burn: A randomized controlled study

Objective

The aim of this study was to investigate the effects of isokinetic training program on muscle strength, muscle size and gait parameters after healed pediatric burn.

Design

Randomized controlled trial.

Subjects

Thirty three pediatric burned patients with circumferential lower extremity burn with total body surface area (TBSA) ranging from 36 to 45%, and ages from 10 to 15 years participated in the study and were randomized into isokinetic group and a control group. Non-burned healthy pediatric subjects were assessed similarly to burned subjects and served as matched healthy controls.

Methods

Patients in the isokinetic group (n = 16) participated in the isokinetic training program for 12 weeks for quadriceps dominant limb, 3 times per week, at angular velocity 150°/s, concentric mode of contraction, time rest between each set for 3 min, 3 sets/day and control group (n = 17) participated in home based physical therapy exercise program without isokinetic.

Main measures

Assessment of quadriceps strength by isokinetic dynamometer, quadriceps size and gait parameters were performed at baseline and at the end of the training period for both groups.

Results

Patients in isokinetic group showed a significant improvement in quadriceps strength, quadriceps size and gait parameters as compared with those in the control group. Quadriceps strength and percentage of improvement was 79.25 ± 0.93 Nm (68.40%) for isokinetic group and 51.88 ± 1.31 Nm (9.84%) for the control group. Quadriceps size and percentage of improvement was 31.50 ± 0.89 cm (7.47%) for isokinetic group and 29.26 ± 1.02 cm (1.02%) for the control group. Stride length, step length, velocity and cadence and percentage of improvement for isokinetic group was 135.50 ± 2.82 (53.97%), 63.25 ± 2.97 (63.77%), 135.94 ± 1.65 (81.42%), 137.63 ± 1.36 (66.96%) and for the control group was 94.00 ± 2.69 (6.68%), 43.76 ± 1.34 (15.15%), 81.11 ± 1.91 (8.6%), 90.35 ± 1.32 (9.01%) respectively.

Conclusions

Participation in the isokinetic training program resulted in a greater improvement in quadriceps muscle strength, size and gait parameters in pediatric burn.     

Laparoendoscopic Single-site Partial Nephrectomy Without Ischemia for Very Small,Exophytic Renal Masses: Surgical Details and Functional Outcomes

Background

Laparoendoscopic single-site surgery (LESS) has emerged as a natural progression from standard laparoscopy aiming to further minimize the morbidity of urologic procedures.

Objective

To describe our technique and report the surgical and functional outcomes of unclamped LESS partial nephrectomy (PN) in the treatment of small renal masses (SRMs).

Design, setting, and participants

Prospective evaluation of pre- and postoperative variables of patients undergoing the LESS-PN without ischemia between 2009 and 2012. The indications were single exophytic SRMs.

Surgical procedure

Unclamped LESS-PN was performed through a transperitoneal approach. A pararectal Hasson access technique was preferred. Single-port access was achieved via different single-port devices. A combination of straight and articulating laparoscopic instruments was used. The tumor was excised using bipolar scissors during normal renal perfusion. Hemostasis was achieved by bipolar electrocautery, parenchymal stitches, and hemostatic agents.

Outcome measurements and statistical analysis

Demographic, operative, postoperative, and pathologic outcomes data were recorded and analyzed.

Results and limitations

A total of 21 LESS-PN were performed (operative time: 111 ± 41 min; blood loss: 196 ± 195 ml: tumor size: 2.0 ± 0.3 cm). Neither conversion to open surgery nor transfusions occurred. Three patients required conversion to standard laparoscopy. Postoperatively, three complications (Clavien grades 2, 3a, and 4) were recorded. Pathologic examination revealed 14 clear cell carcinomas, four renal cysts, two oncocytomas, and one angiomyolipoma. Hospital stay was 4.4 ± 1.9 d. At the last follow-up (mean: 17 ± 11.5 mo), no port-site, local, or distant recurrences were detected. No significant variation in serum creatinine and estimated glomerular filtration rate was observed. Subjective scar evaluation indicated 66% of patients were very satisfied/enthusiastic. Study limitations include the small sample size, the lack of a control group, the short follow-up period, and the arbitrary measure of patient's scar perception.

Conclusions

Unclamped LESS-PN for selected SRMs is a safe and feasible procedure providing favorable postoperative outcomes and ensuring high levels of subjective, cosmetic satisfaction.     

Erosive pustular dermatosis: New description of a possible cause of the non-healing burn wound

Introduction

Erosive pustular dermatosis (EPD) is a cutaneous condition, characterised by sterile pustular lesions, erosions and crusting. Extensive or infected disease may result in scarring. EPD has never been reported following burn. The aim of this study was to describe the presentation and management of EPD complicating burns wounds.

Methods

A consecutive series of EPD cases secondary to burn.

Results

Six cases were identified. In each case, erosive lesions and crusts were located at the site of burn or at the site of split skin grafting after tangential burn excision. All cases presented as failure to heal or repeated wound breakdown, despite standard burn wound management. Pain was a significant feature in all cases. Microbiological cultures demonstrated either benign colonising bacteria or no pathogens. Time to EPD diagnosis by the interdisciplinary team was 126 ± 27 days (mean ± SEM). Topical therapy with short course, potent corticosteroids resulted in clinical remission in 15 ± 2 days (mean ± SEM) without clinical relapses after 15 ± 4 months (mean ± SEM).

Conclusion

EPD may occur following burns. EPD should be considered in the differential diagnosis of a non-healing burn wound and resolves readily with topical potent corticosteroid therapy.     

Interest of BIS monitoring to guide propofol infusion during the anhepatic phase of orthotopic liver transplantation

Objective

The anhepatic phase of orthotopic liver transplantation (OLT) is associated with significant changes in pharmacokinetics. The aim of this study was to compare the influence of this phase on propofol target concentrations during BIS guided target controlled infusion (TCI).

Study design

Prospective study.

Patients and methods

Eight patients aged 25 to 65 years, Child-Pugh status A-B scheduled for OLT were prospectively included. Anesthesia was performed using TCI of propofol (Diprifusor^®, Marsh pharmacokinetic model), sufentanil and cisatracurium. Propofol target concentration was adjusted to maintain BIS values between 40 and 50.

Results

To maintain stable BIS values, propofol target concentrations should be decreased during the anhepatic phase versus the dissection one (2.0 μg/ml ± 0.8 versus 3.0 μg/ml ± 0.9, p < 0.0001).

Conclusion

BIS could be useful to titrate propofol infusion during the anhepatic phase of OLT.     

Three-year Oncologic and Renal Functional Outcomes After Robot-assisted Partial Nephrectomy

Background

With the wider adoption of minimally invasive partial nephrectomy (PN), intermediate- and long-term outcomes data are needed to make firm conclusions about oncologic and functional efficacy, especially for robot-assisted PN (RPN).

Objective

To report intermediate-term oncologic and renal functional outcomes of RPN.

Design, setting, and participants

We performed a chart review of patients who had undergone RPN since June 2006; patients with a minimum of 2 yr of follow-up were included in this study. Length of follow-up was calculated from the date of surgery to the date of last clinical follow-up. Patients who were either lost to follow-up or who had follow-up outside of our center were sent surveys.

Intervention

Transperitoneal RPN with or without hilar clamping.

Outcome measurements and statistical analysis

The demographic, preoperative, and postoperative data were statistically analyzed. The Kaplan-Meier method was used to calculate overall survival (OS), cancer-specific survival (CSS), and cancer-free survival (CFS). Upstaging of chronic kidney disease (CKD) was calculated, as well. Univariate and multivariate analyses were performed to show predicting factors for the latest estimated glomerular filtration rate (eGFR).

Results and limitations

Of 427 patients, 134 had a minimum follow-up of 2 yr, and 70 had a minimum of 3–6 yr of follow-up. The mean age was 59.1 ± 12.5 yr, body mass index (BMI) was 29.8 ± 6.2 kg/m², and Charlson comorbidity index (CCI) score was 4.2 ± 1.6. The mean tumor size on computed tomography (CT) scan was 3.0 ± 1.6 cm, RENAL score was 7.2 ± 1.8, estimated blood loss (EBL) was 270.7 ± 291.9 ml, operative time was 189.1 ± 54.8 min, and warm ischemia time (WIT) was 17.9 ± 10.3 min. A total of two intraoperative complications (1.5%) and five high-grade Clavien complications (3.7%) occurred. Patients stayed on average for 3.7 ± 1.7 d in the hospital, and the average follow-up was 3.0 ± 0.9 yr. OS was 97.01% at 3 yr and 90.20% at 5 yr; CFS was 98.92% at 3 yr and 98.92% at 5 yr; and CSS was 99.04%, as projected by the Kaplan-Meier method. The mean preoperative GFR was 88.2 ± 0.8 ml/min per 1.73 m²; the latest postoperative GFR was 80 ± 24 ml/min per 1.73m², with a 8 ± 17.4% change. There was a 20.2% upstaging of CKD postoperatively, but no patients started dialysis.

Conclusions

This study reaffirms that RPN is effective in renal function preservation and oncologic control at an intermediate follow-up interval.     

Impact of the Learning Curve on Perioperative Outcomes in Patients Who Underwent Robotic Partial Nephrectomy for Parenchymal Renal Tumours

Background

Robot-assisted partial nephrectomy (RAPN) is an emerging, minimally invasive technique to treat patients with small renal masses.

Objective

To evaluate the impact of the learning curve on perioperative outcomes such as operative times and warm ischaemia times (WIT), blood loss, overall complications, and renal function impairment in patients who underwent RAPN.

Design, setting, and participants

We collected prospectively the clinical and pathologic records of 62 consecutive patients who underwent RAPN between September 2006 and November 2009 for renal tumours at a nonacademic teaching institution by a single surgeon with extensive prior robotic experience.

Interventions

The surgeon used transperitoneal RAPN with excision of an adequate rim of healthy peritumour renal parenchyma.

Measurements

Perioperative parameters, pathologic outcome, and short-term outcomes for renal function were recorded. The effects of the learning curve on the previous reported perioperative and functional outcomes was studied.

Results and limitations

The mean pathologic tumour size was 2.8 ± 1.3 cm. A pelvicaliceal repair was needed in 33 cases (53%). The mean console time was 91 ± 33 min (range: 52–180), with a mean WIT of 20 ± 7 min (range: 9–40). Warm ischaemia (<20 min) and console times were optimised after the first 30 (p < 0.001) and 20 cases (p < 0.001), respectively. Pathologic results yielded a positive surgical margin (PSM) rate of 2%. Mean creatinine level changed from a baseline value of 1.02 ± 0.38 mg/dl to 1.1 ± 0.7 mg/dl 3 mo after surgery. Estimated glomerular filtration rate changed from a baseline value of 81.17 ± 29 to 80.5 ± 29 (millilitres per minute per 1.73 m²) 3 mo postoperatively.

Conclusions

RAPN is a viable option for nephron-sparing surgery in patients with renal carcinoma. Specifically, in the hands of a surgeon with extensive robotic experience, RAPN requires a short learning curve to reach WIT <20 min, console times <100 min, limited blood loss, and acceptable overall complication rates.     

Single-Port Laparoscopic and Robotic Partial Nephrectomy

Background

Partial nephrectomy (PN) for small renal masses provides effective oncologic outcomes. Single-port laparoscopic (SPL) and robotic surgeries are evolving approaches to advance minimally invasive surgery.

Objective

To determine the feasibility of laparoscopic and robotic single-port PN.

Design, setting, and participants

Since 2007, evaluation of patients undergoing SPL and single-port robotic (SPR) PN at a primary referral center was performed. Patients with small, solitary, exophytic-enhancing renal masses were selected. Patients with a solitary kidney, endophytic or hilar tumors, and previous abdominal and/or kidney surgery were excluded. Perioperative and pathologic data were entered prospectively into an institutional review board (IRB)–approved database.

Interventions

Tumor location determined either an open Hasson transperitoneal or retroperitoneal approach. A single multichannel port or Triport provided intra-abdominal access. The Harmonic Scalpel was used for tumor excision under normal renal perfusion. The da Vinci surgical robot was used for SPR cases.

Measurements

Patient demographics, perioperative, hematologic, and pathologic data as well as pain assessment using the Visual Analog Pain Scale (VAPS) were assessed.

Results and limitations

A total of seven patients underwent single-port PN (SPL = 5, SPR = 2). One patient with a right anterior upper-pole mass required conversion from SPL to standard laparoscopy following tumor excision because of intraoperative bleeding. Pathology revealed six lesions compatible with renal cell carcinoma (RCC) and one benign cyst. One negative frozen section came back focally positive on final histopathology. All other surgical margins were negative. A mean difference of 3.0 ± 2.0 g/dl in hemoglobin was noted in all patients. Minimal pain was noted at discharge following both laparoscopic and robotic single-port surgery (VAPS = 1.7 ± 1.2 vs 1 ± 0.5/10).

Conclusions

SPL and SPR PN is feasible for select exophytic tumors. Robotics may improve surgical capabilities during single-port surgery.     

Operative Details and Oncological and Functional Outcome of Robotic-Assisted Laparoscopic Radical Prostatectomy: 400 Cases with a Minimum of 12 Months Follow-up

Background

Robotic-assisted laparoscopic radical prostatectomy (RALP) using the da Vinci^® surgical system (Intuitive Surgical, Sunnyvale, CA) is increasingly used for the management of localised prostate cancer.

Objective

We report the operative details and short-term oncological and functional outcome of the first 400 RALPs performed at our unit.

Design, setting and participants

From December 2003 to August 2006, 400 consecutive patients underwent RALP at our institution. A prospective database was established to record the relevant details of all RALP cases.

Surgical procedure

A six port transperitoneal approach using a 4-arm da Vinci^® system was used to perform RALP. This database was reviewed to establish the operative details and oncological and functional outcome of all patients with a minimum of 12 months follow-up.

Measurements

Perioperative characteristics and outcomes are reported. Functional outcome was assessed using continence and erectile function questionnaires. Biochemical recurrence (prostate-specific antigen (PSA) ≥0.2 ng/mL) is used as a surrogate for cancer control.

Results and limitations

The mean age ± standard deviation (SD) was 60.2 ± 6 years. Median PSA level was 7.0 (interquartile range (IQR) 5.3–9.6) ng/mL. The mean operating time ± SD was 186 ± 49 mins. The complication rate was 15.75% comprising Clavien grade I-II and Clavien grade III complications in 10.5% and 5.25% of patients respectively.The overall positive surgical margin rate was 19.2% with T2 and T3 positive margin rates of 9.6% and 42.3% respectively. The biochemical recurrence-free survival was 86.6% at a median follow-up of 22 (IQR = 15–30) months. At 12 months follow-up, 91.4% of patients were pad-free or used a security liner. Of those men previously potent (defined as Sexual Health Inventory for Men [SHIM] score ≥21) who underwent nerve-sparing RALP, 62% were potent at 12 months.

Conclusions

The safety and feasibility of RALP has already been established. Our initial experience with this procedure shows promising short-term outcomes.     

Influence du mode de ventilation sur la variation respiratoire de la pression pulsée artérielle : étude randomisée

Objective

Pulse pressure variation (ΔPP) has been demonstrated to be an accurate dynamic parameter to predict fluid responsiveness. However, the impact of different ventilator modes on this parameter is unknown. We compared ΔPP values calculated alternatively during pressure- and volume-controlled ventilation.

Study design

Double-blind randomized study, cross-over design.

Patients

Patients in intensive care unit after a cardiac surgery.

Method

Patients were ventilated alternatively in both ventilator modes (according to the randomization): volume-controlled ventilation (VVC) and pressure-controlled ventilation (VPC). Other parameters of ventilation were identical. ΔPP values were calculated for each patient in both ventilator modes.

Results

Among the 26 patients analyzed, mean ΔPP value was de 14.0 ± 7.3% in VVC and 11.8 ± 6.2% in VPC (P < 0,0001). On Bland-Altman representation, mean bias was +2.2 ± 2.3% and inferior and superior limits of agreement were respectively −2.3 and 6.7%. Arterial blood pressure and central venous pressure were not modified.

Conclusion

ΔPP values obtained with both ventilator modes were not interchangeable. On average, ΔPP decreases by more than two points in the passage VVC to VPC for a given patient, all others things being equal.     

National trends in pediatric blunt spleen and liver injury management and potential benefits of an abbreviated bed rest protocol

Purpose

Recent reports suggest that an abbreviated bed rest protocol (ABRP) may safely reduce length of stay (LOS) and resource utilization in pediatric blunt spleen and liver injury (BSLI) patients. This study evaluates national temporal trends in BLSI management and estimates national reduction in LOS using an ABRP.

Methods

Pediatric patients (< 18 years old) sustaining BLSI were identified in the Kids’ Inpatient Database from 2000 to 2009. Yearly rates of injury and operative intervention were examined and stratified by type of injury. APSA guidelines and the reported ABRP were applied based on abbreviated injury score (AIS) and compared with actual LOS.

Results

22,153 patients were identified. Over the study period, operative rates for spleen and liver injuries and overall mortality significantly declined: LOS = 3.1 days (± 1.6) and 2.7 days (± 1.9) for spleen and liver, respectively. If APSA guidelines were followed, the rates were LOS = 3.7 days (± 1.1) and 3.4 days (± 0.7), respectively. Application of the ABRP would result in LOS = 1.3 days (± 0.5) for all BSLI patients. An ABRP could potentially save 1.7 hospital days/patient or 36,964 patient hospital days nationally.

Conclusion

Our study confirms a significant national decrease in operative intervention and overall mortality in patients with BSLI. Additionally, it appears that a shorter observation period than the APSA guidelines is being utilized. The implementation of ABRP holds potential in further reducing LOS and resource utilization.     

Eraser Laser Enucleation of the Prostate: Technique and Results

Background

Eraser, a 1318-nm diode laser, has been used for 15 yr for resection of lung metastases. It was recently introduced in urology for small kidney tumors and for the treatment of benign prostatic obstruction.

Objective

To demonstrate on video our technique of Eraser laser enucleation of the prostate (ELEP) and report our experience.

Design, setting, and participants

From June 2010 to October 2011, 43 consecutive patients were prospectively evaluated. All of them had lower urinary tract symptoms suggestive of benign prostatic obstruction and a mean prostate size of 59.9 ml (range: 34–89 ml) on transrectal ultrasound. Their mean prostate-specific antigen value was 3.4 ng/ml (range: 0.8–5.0 ng/ml); mean maximum flow rate (Q_max), 6.9 ml/s (range: 2–11 ml/s); mean International Prostate Symptom Score (IPSS), 25.9 (range: 18–32); and mean postvoid residual (PVR), 170.5 ml (range: 60–330 ml).

Surgical procedure

The details of the technique are shown on video.

Outcome measurements and statistical analysis

Success was defined as patients being able to void with improved IPSS, Q_max, PVR volume, and ameliorated quality of life.

Results and limitations

The mean operating time was 67.0 ± 11.43 min. Mean serum hemoglobin was 15.1 ± 0.87 g/l before, and 14.39 ± 0.94 g/l after surgery. Mean blood loss was 115.90 ± 98.12 ml. No blood transfusions were required. All patients had their catheters removed within 2 d and were able to void spontaneously after this time. Significant improvements were noted in Q_max, quality of life, IPSS, and PVR volume from baseline to each follow-up time point.Based on the validated Clavien-Dindo system, we observed one grade 1d complication, one grade 2 complication, and one grade 3b complication.

Conclusions

ELEP is a safe and reproducible method for relieving bladder outflow obstruction and lower urinary tract symptoms. Its advantages include minimal blood loss, short catheterization time, and a brief hospital stay.     

Transosseous suturing of patellar fractures with braided polyester – A prospective cohort with a matched historical control study

Background

Although tension-band wiring is the most widely used technique to fix patellar fractures, metal implant-related complications including implant failure and postoperative pain are very common and additional procedures are often necessary to treat the complications. The purpose of this study is to evaluate a totally metal-free technique using a transosseous suturing method and to compare it with the traditional fixation technique.

Method

A total of 25 patients (mean age of 59.60 years) with displaced patellar fractures treated by a transosseous suturing technique were compared with a 1:1 matched historical control group that underwent modified tension-band-wire fixation. Union time, union rate, operation time, number of procedures, mean hospitalisation days and complications were compared between cases and controls.

Results

Union time (8.43 ± 2.92 vs. 8.64 ± 2.82 weeks) and operation time (69.00 ± 19.31 vs. 64.89 ± 14.27 min) were not different between the two groups. Mean hospitalisation days (4.04 ± 1.40 vs. 5.76 ± 1.50 days; P < 0.001), number of procedures and the frequency of complications were significantly lower in the transosseous suturing group.

Conclusion

The transosseous suturing technique is safe and effective in the transverse or comminuted fractures of the patella. The complication rate is significantly lower than with the tension-band-wiring technique.     

Titration morphinique intraveineuse en salle de surveillance post-interventionnelle (SSPI) après chirurgie bariatrique sous cœlioscopie

Objective

There is limited information available regarding intravenous (IV) morphine admistration in obese patients in PACU. The aim of this study was to compare two IV morphine titration (IMT) regimen in two surgical centers.

Study design

Observational study.

Patients

Laparoscopic bariatric surgery in one private (Saint-Grégoire Clinic) and one public (University Hospital of Amiens) surgical center.

Methods

A strict and common protocol of IMT was implemented if PACU of both centers according to the recommendations of the French Society of Anaesthesia and Intensive Care. When pain score increased to > 30, IMT was titrated every 5 min in 3 mg increments until pain relief (VAS ≤30 mm). Pain level, dose of morphine (per total and ideal body weight), effectiveness, and side events were recorded.

Results

Data were recorded for 159 adult patients (129 women). Mean age and BMI were 42 ± 12 yrs and 43.8 ± 6.9 kg/m². Ninety-eight patients were eligible for IMT regimen but only 76 patients received IV morphine (47.8 %). Mean dose was 7.3 mg ± 3.5 mg [1–19 mg], (60.4 μg/kg and 115.8 μg/kg). IMT was less frequent, mean dose was greater (8.6 ± 4.2 vs 6.2 ± 2.9 mg) and number of patients with pain relief was higher (73.7 vs 35.6 %) in the public hospital. No severe adverse events have been recorded and there was no difference in both centers regarding these events.

Conclusion

Implementation of a IMT regimen in PACU was not associated with effective pain relief after laparoscopic surgery in obese patients.