Outcome of Patients with Esophageal Perforations: A Multicenter Study

Background

Recent studies have suggested that stent-grafting may improve the treatment outcome of patients with esophageal perforation, but evidence on this is still lacking.

Methods

Data on 194 patients who underwent conservative (43 patients), endoclip (4 patients) stent-grafting (63 patients) or surgical treatment (84 patients) for esophageal perforation were retrieved from nine medical centers.

Results

In-hospital/30-day mortality was 17.5 %. Three-year survival was 67.1 %. Age, coronary artery disease, and esophageal malignancy were independent predictors of early mortality. Chi squared automatic interaction detection analysis showed that patients without coronary artery disease, without esophageal malignancy and younger than 70 years had the lowest early mortality (4.1 %). Surgery was associated with slightly lower early mortality (conservative 23.3, endoclips 25.0 %, stent-grafting 19.0 %, surgery 13.1 %; p = 0.499). One center reported a series of more than 20 patients treated with stent-grafting which achieved an early mortality of 7.7 % (2/26 patients). Stent-grafting was associated with better survival with salvaged esophagus (conservative 76.7 %, endoclips 75.0 %, stent-grafting 77.8 %, surgery 56.0 %; p = 0.019). Propensity score adjusted analysis showed that stent-grafting achieved similar early mortality (p = 0.946), but significantly higher survival with salvaged esophagus than with surgical treatment (p = 0.001, OR 0.253, 95 % CI 0.110–0.585). Primary surgical repair was associated with somewhat lower early mortality (14.6 vs. 19.0 %; p = 0.561) and better survival with salvaged esophagus (85.4 vs. 77.8 %; p = 0.337) than stent-grafting.

Conclusions

Esophageal perforation was associated with a rather high mortality rate in this all-comers population. Stent-grafting failed to decrease operative mortality, but it improved survival with salvaged esophagus. The results of one of the centers indicate that increasing experience with this less invasive procedure may possibly improve the outcome of these patients.     

Synchronous Bilateral Adrenalectomy for Cushing’s Syndrome: Laparoscopic Versus Posterior Retroperitoneoscopic Versus Robotic Approach

Background

Synchronous endoscopic bilateral adrenalectomy (BilA) can effectively provide definitive cure of hypercortisolism in ACTH-dependent Cushing’s syndrome and in primary adrenal bilateral disease. We compared three different approaches for BilA: transabdominal laparoscopic BilA (TL-BilA), simultaneous posterior retroperitoneoscopic BilA (PR-BilA), and robot-assisted BilA (RA-BilA).

Methods

All patients who underwent BilA between January 1999 and December 2012 at two referral centers (one performing TL-BilA and PR-BilA and one performing RA-BilA) were included. A comparative analysis was performed.

Results

Twenty-nine patients were included: 5 underwent TL-BilA, 11 underwent PR-BilA, and 13 underwent RA-BilA. No significant difference was found concerning age, gender, diagnosis, and previous abdominal surgery. No conversion to open approach was registered. Operative time was significantly shorter for the PR-BilA group than for the TL-BilA and RA-BilA groups (157.4 ± 54.6 vs 256.0 ± 43.4 vs 221.5 ± 42.2 min, respectively) (P < 0.001). No significant difference was found concerning intraoperative and postoperative complications rate and time to first flatus. Drains were used routinely after PR-BilA and TL-BilA and electively in four RA-BilA patients (P < 0.001). Hospital stay was longer in the TL-BilA and PR-BilA groups than in the RA-BilA group (12.0 ± 5.7 vs 10.8 ± 3.7 vs 4.4 ± 1.7 days, respectively) (P < 0.001). No recurrence or disease-related death was registered.

Conclusions

Operative time was significantly shorter in the PR-BilA group, because it eliminates the need to reposition the patient. The number of drains and the length of hospital stay were reduced after RA-BilA, but this was likely related to different management protocols in different settings. Because no significant difference was found in terms of postoperative outcome, none of the three operative approaches can be considered the preferable one.     

An acceleromyographic train-of-four ratio of 1.0 reliably excludes respiratory muscle weakness after major abdominal surgery: a randomized double-blind study

Purpose

This randomized double-blind study was designed to determine if respiratory muscle weakness – measured by maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP), forced vital capacity (FVC), and forced expiratory volume in one second (FEV₁) – persists even if an acceleromyographic train-of-four ratio (TOFR) of 1.0 is reached after major abdominal surgery.

Methods

Twenty patients underwent respiratory function tests before induction of anesthesia. Rocuronium was given, and the tests were repeated after extubation when the TOFR reached 1.0. The patients were then randomized to receive sugammadex 1 mg·kg^-1 or placebo, and the same tests were repeated five and 20 min later. Between-group comparisons were carried out with a mixed-model analysis of variance analysis.

Results

After anesthesia and adequate epidural analgesia, MIP and MEP decreased by 60% in both groups. In the placebo group, MIP decreased from a pre-induction value (median [range]) of 61.8 [31.3-96.1] to 19.6 [8.3-58.3] cm H₂O after extubation without significant variation five and 20 min after placebo. In the sugammadex group, MIP decreased from a pre-induction value of 57.8 [13.0-96.4] to 20.5 [6.4-67.3] cm H₂O after extubation. No differences were recorded after sugammadex administration (P = 0.246 between groups). In the placebo group, MEP decreased from 88.8 [65.1-120.3] before induction to 37.6 [13.4-70.6] cm H₂O after extubation. In the sugammadex group, MEP decreased from 85.5 [58.6-132.7] to 30.8 [10.5-60.5] cm H₂O, with no improvement five and 20 min after either placebo or sugammadex administration (P = 0.648). Similarly, the FCV and FEV₁ decreased 30-40% after extubation in both study groups.

Conclusion

Acceleromyographic TOFR of 1.0 excludes residual neuromuscular paralysis. However, major respiratory dysfunction is observed after abdominal surgery. This trial was registered at ClinicalTrials.gov: NCT01503840.     

Ultra-high-resolution paleoenvironmental records via direct laser-based analysis of lipid biomarkers in sediment core samples

Marine microorganisms adapt to their habitat by structural modification of their membrane lipids. This concept is the basis of numerous molecular proxies used for paleoenvironmental reconstruction. Archaeal tetraether lipids from ubiquitous marine planktonic archaea are particularly abundant, well preserved in the sedimentary record and used in several molecular proxies. We here introduce the direct, extraction-free analysis of these compounds in intact sediment core sections using laser desorption ionization (LDI) coupled to Fourier transform ion cyclotron resonance mass spectrometry (FTICR-MS). LDI FTICR-MS can detect the target lipids in single submillimeter-sized spots on sediment sections, equivalent to a sample mass in the nanogram range, and could thus pave the way for biomarker-based reconstruction of past environments and ecosystems at subannual to decadal resolution. We demonstrate that ratios of selected archaeal tetraethers acquired by LDI FTICR-MS are highly correlated with values obtained by conventional liquid chromatography/MS protocols. The ratio of the major archaeal lipids, caldarchaeol and crenarchaeol, analyzed in a 6.2-cm intact section of Mediterranean sapropel S1 at 250-µm resolution (∼4-y temporal resolution), provides an unprecedented view of the fine-scale patchiness of sedimentary biomarker distributions and the processes involved in proxy signal formation. Temporal variations of this lipid ratio indicate a strong influence of the ∼200-y de Vries solar cycle on reconstructed sea surface temperatures with possible amplitudes of several degrees, and suggest signal amplification by a complex interplay of ecological and environmental factors. Laser-based biomarker analysis of geological samples has the potential to revolutionize molecular stratigraphic studies of paleoenvironments.Microbial lipids in aquatic sediments reflect phylogeny, environmental conditions, and biogeochemistry of the water column in which they were produced. After sedimentation and because of the persistence of lipid structures in the sedimentary record, the information archived in these lipids remains available on geological time scales. Retrieval of this information from sediments and rocks has increasingly contributed to our understanding of past environments, microbial communities, and biogeochemical processes (e.g., refs. 1–5). Merged with the concept of molecular stratigraphy (2, 6), i.e., the analysis of selected biomarkers in solvent extracts of sediment samples in a stratigraphic framework, unique information can be gleaned regarding the temporal changes of past ecological and environmental conditions in aquatic systems. Because of analytical requirements, the temporal resolution is typically limited by centimeter-scale-sized samples, which, dependent on the depositional setting, tend to integrate time periods of decades to millennia, even in high-sedimentation settings such as the Santa Barbara Basin (e.g., refs. 4, 7, 8). In consequence, our knowledge of the temporal changes of the environmental and ecological history recorded by lipid biomarkers is rather coarse and based on long-term averages of their distributions in the sedimentary record.In this study we seek to extend this approach to ultra-high-resolution molecular stratigraphy. We focused on archaeal glycerol dialkyl glycerol tetraethers (GDGTs), which are produced by planktonic archaeal communities and are ubiquitous and persistent components in marine sediments (e.g., refs. 9, 10) with widely recognized potential for paleoenvironmental studies. The number of cycloalkyl rings in GDGTs (Fig. S1) appears highly sensitive to ecological and environmental factors such as phylogeny (ref. 5 and references therein), temperature (ref. 11 and references therein), or pH (12, 13). This sensitivity of GDGT composition to environmental and ecological factors has driven the development of multiple molecular proxies. Adaptation to temperature has been demonstrated in thermophilic cultures of archaea (e.g., ref. 14) and serves as concept for the reconstruction of paleo sea surface temperatures (SST) in sediments using the TEX₈₆ (tetraether index of 86 carbon atoms) (3), which is based on fossil lipids of planktonic archaea. This proxy has been used to characterize oscillations of SST in different geological episodes (e.g., refs. 8, 15, 16). Complications could arise from additional GDGT sources, e.g., allochthonous inputs of GDGT-bearing soils, lateral transport, in situ production, and/or recycling by sedimentary archaea (cf. refs. 5, 17). Relative GDGT distributions required for proxy calculations are obtained by HPLC atmospheric pressure chemical ionization mass spectrometry (HPLC/APCI-MS) of solvent extracts from gram-sized sediment samples (18, 19).To enhance temporal resolution of GDGT-based proxies, we explored the utility of laser desorption ionization coupled to Fourier transform ion cyclotron resonance mass spectrometry (LDI FTICR-MS). In LDI, the impact of a pulsed laser beam on the sample leads to desorption, vaporization and ionization of the analytes, forming a cloud of charged molecules. An additional matrix is frequently applied to facilitate the generation of ions (matrix assisted laser desorption ionization [MALDI]). A complete understanding of underlying ionization mechanisms has not been achieved yet (20). LDI or MALDI are best known in the field of proteins or peptides and have also been successfully used in lipid research (21). The fact that LDI analysis can generate ions directly from the sample placed on a sample holder without time-consuming wet-chemical pretreatment while producing mass spectra from submillimeter-sized spots (as small as 10 µm) makes this technique particularly attractive for molecular stratigraphy. LDI may allow direct analysis of nanogram-sized samples on the surface of cut, intact sediment cores at ultra-high spatial resolution, equivalent to temporal resolution on the order of months to decades.We aimed to develop a technique that takes advantage of both the exquisite sensitivity and unequivocal molecular information of ultra-high-resolution mass spectrometry by FTICR-MS and the high spatial resolution of LDI within an intact and unaltered sedimentological context. The key steps of validation and implementation included (Fig. S2) (i) the detection of archaeal GDGTs, (ii) verification of results obtained by LDI FTICR-MS by parallel analysis using established HPLC/APCI-MS methods, and (iii) the examination of the first continuous high-resolution GDGT profile from a sediment core section of the eastern Mediterranean sapropel S1, which was deposited under anoxic conditions during the Holocene climatic optimum (HCO; refs. 22, 23). The data thus may provide an unprecedented view of the dynamic variations of both SST and ecological and environmental factors during sapropel formation.     

Increasing homogeneity in global food supplies and the implications for food security

The narrowing of diversity in crop species contributing to the world’s food supplies has been considered a potential threat to food security. However, changes in this diversity have not been quantified globally. We assess trends over the past 50 y in the richness, abundance, and composition of crop species in national food supplies worldwide. Over this period, national per capita food supplies expanded in total quantities of food calories, protein, fat, and weight, with increased proportions of those quantities sourcing from energy-dense foods. At the same time the number of measured crop commodities contributing to national food supplies increased, the relative contribution of these commodities within these supplies became more even, and the dominance of the most significant commodities decreased. As a consequence, national food supplies worldwide became more similar in composition, correlated particularly with an increased supply of a number of globally important cereal and oil crops, and a decline of other cereal, oil, and starchy root species. The increase in homogeneity worldwide portends the establishment of a global standard food supply, which is relatively species-rich in regard to measured crops at the national level, but species-poor globally. These changes in food supplies heighten interdependence among countries in regard to availability and access to these food sources and the genetic resources supporting their production, and give further urgency to nutrition development priorities aimed at bolstering food security.A shared axiom of ecology and nutrition is that, within certain ranges, diversity enhances the health and function of complex biological systems. Species diversity has been shown to stimulate productivity, stability, ecosystem services, and resilience in natural (1–5) and in agricultural ecosystems (6–13). Likewise, variation in food species contributing to diet has been associated with nutritional adequacy (14–17) and food security (18).The development of sedentary agricultural societies and further rise of modern agriculture is generally considered to have led to a decline in the total number of plant species upon which humans depend for food (19, 20), particularly the wild, semidomesticated, and cultivated vegetables and fruits, spices, and other food plants that supplemented staple crops with the provision of micronutrients and that bolstered food security historically during crop failures (21). Harlan (20) warned that

most of the food for mankind comes from a small number of crops and the total number is decreasing steadily. In the United States in the past 40 years, many vegetables and fruits have disappeared from the diet, and the trend is going on all over the world. More and more people will be fed by fewer and fewer crops.

More recent analyses of dietary transition in developing countries in association with globalization have noted increases in the diversity of plants contributing to diets locally, along with a Westernization transition in preference of energy-dense foods (i.e., animal products, plant oils, and sugars) over cereals, pulses, and vegetables, and of particular major crop plants within these food categories over traditional crops (22, 23). The impact of such changes on overall crop diversity worldwide has not been comprehensively documented, although recent changes in varietal and allelic level diversity of some crops have been investigated (24–26). Given the potential food security implications of narrowing of the diversity of crop species both in production systems and in food supplies, an assessment of the global state of crop plant species diversity is warranted.Here we examine changes in the diversity of the portfolio of crop species upon which humans primarily depend for food security in regard to calories, protein, fat, and food weight. Using national per capita food supply data published by the Food and Agriculture Organization (FAO) of the United Nations, we analyzed trends in the richness, abundance, and composition of measured crop commodities in the food supplies of 152 countries comprising 98% of the world’s population from 1961 to 2009.     

Fine-scale ecological and economic assessment of climate change on olive in the Mediterranean Basin reveals winners and losers

The Mediterranean Basin is a climate and biodiversity hot spot, and climate change threatens agro-ecosystems such as olive, an ancient drought-tolerant crop of considerable ecological and socioeconomic importance. Climate change will impact the interactions of olive and the obligate olive fruit fly (Bactrocera oleae), and alter the economics of olive culture across the Basin. We estimate the effects of climate change on the dynamics and interaction of olive and the fly using physiologically based demographic models in a geographic information system context as driven by daily climate change scenario weather. A regional climate model that includes fine-scale representation of the effects of topography and the influence of the Mediterranean Sea on regional climate was used to scale the global climate data. The system model for olive/olive fly was used as the production function in our economic analysis, replacing the commonly used production-damage control function. Climate warming will affect olive yield and fly infestation levels across the Basin, resulting in economic winners and losers at the local and regional scales. At the local scale, profitability of small olive farms in many marginal areas of Europe and elsewhere in the Basin will decrease, leading to increased abandonment. These marginal farms are critical to conserving soil, maintaining biodiversity, and reducing fire risk in these areas. Our fine-scale bioeconomic approach provides a realistic prototype for assessing climate change impacts in other Mediterranean agro-ecosystems facing extant and new invasive pests.The Mediterranean Basin is a climate change (1) and biodiversity (2) hot spot where substantial warming is predicted in the next few decades (3). A 2 °C increase in average temperature is a widely used metric for assessing risks associated with global warming and as a policy reference, and this level of warming will likely occur in the Basin between 2030 and 2060 (4) with unknown biological and economic impact on major crop systems. Small differences in average climate warming are predicted for the Basin by A1B and higher greenhouse-gases (GHG) forcing scenarios within the 2050 time horizon (5).A major agro-ecosystem in the Basin is olive (Olea europaea L.), an ancient ubiquitous crop of considerable socioeconomic importance (6). A detailed review of methods used to assess the impact of weather and of climate change on the olive system is given in SI Appendix. Most of the crop is used to produce olive oil, with Basin countries producing 97% of the world supply (International Olive Council, www.internationaloliveoil.org/). Olive is a long-lived drought-tolerant species limited by frost and high temperatures, and to a lesser extent by low soil fertility and soil water (7). Temperatures <−8.3 °C damage olive and limit its northward distribution, whereas annual rainfall <350 mm y⁻¹ limits its distribution in arid regions. Commercial olive production occurs in areas with >500 mm rainfall y⁻¹ (SI Appendix, Fig. S1). Climate models predict increased temperatures for the Mediterranean Basin in response to increasing [GHG], but only a weak negative trend in precipitation and no trend in evaporation are predicted (8). Growth rates in some plants will increase with [CO₂] within their thermal and moisture limits (7, 9), but the response for olive is unknown.Mainstream assessments of climate change impact on agricultural and other ecosystems have omitted trophic interactions (10). Here we include the effects of climate change on olive phenology, growth, and yield, and on the dynamics and impact of its obligate major pest, the olive fruit fly [Bactrocera oleae (Rossi)]. The thermal limits of olive and the fly differ and affect the trophic interactions (11) crucial to estimating the bioeconomic impact of climate change in olive across the Basin.Previous assessments of climate change on heterothermic species have used ecological niche modeling (ENM) approaches that characterize climatically a species’ geographic range based on observed aggregate weather data in areas of its recorded distribution (for olive, see, e.g., ref. 12). ENMs are often used to predict the distribution of the species in response to climate change (13) despite serious deficiencies including the inability to include trophic interactions (14). Moreover, the implicit mathematical and ecological assumptions of ENMs hinder biological interpretation of the results (15).As an alternative we use mechanistic physiologically based demographic models (PBDMs) that explicitly capture the weather-driven biology of interacting species (e.g., ref. 16) and predict the geographic distribution and relative abundance of species across time and space independent of species distribution records using extant and climate change weather scenarios as drivers for the system. The explicit assumptions in PBDMs have heuristic value, and bridge the gap between long run field experiments used to study global change biology and the narrow methodological and conceptual bases of ENM approaches commonly used in macroecology (17, 18). These attributes are essential for assessing the bioeconomic consequences of climate warming on trophic interactions across large landscapes.Linked PBDMs for olive and olive fly in a geographic information system (GIS) context (11) (Fig. 1 and SI Appendix, Fig. S2) are used to estimate the fine-scale ecological and economic impact of climate warming on olive yield and fly infestation across the Basin using baseline daily weather (scenario ) simulated under observed [GHG], and the increasing [GHG] A1B emissions scenario () of the Intergovernmental Panel on Climate Change (IPCC) (Materials and Methods and SI Appendix, SI Materials and Methods).Open in a separate windowFig. 1.Multitrophic biology of the olive/olive fly system. (A) Dry matter flow in olive and to olive fly, and (B) dynamics of olive fly number (see ref. 22).     

Accuracy of preoperative automatic measurement of the liver volume by CT-scan combined to a 3D virtual surgical planning software (3DVSP)

Background

Liver volumetry is a critical component of safe hepatic surgery, in order to minimize the risk of postoperative liver failure. Liver volumes can be calculated routinely using the time-consuming gold standard method of manual volumetry. The current work sought to evaluate an alternative automatic technique based on a novel 3D virtual planning software, and to compare it to the manual technique.

Methods

A prospective study of patients undergoing liver resection was conducted. Every patient had a pre and 2-day postoperative CT-scan. For each patient, total, remnant and resected volumes were calculated manually and automatically. Planes of resection were verified by a hepatobiliary surgeon and compared with postoperative volumes. Paired t-tests and correlation coefficients were calculated.

Results

A major hepatectomy was carried out in 36/43 patients. The automatic TLV (1,759 mL) and the manual TLV (1,832 mL) were significantly different (p < 0.001), but extremely highly correlated (r = 0.989). The percentages of preoperative RLV (manual 58.5 %, automatic 58.9 %) were similar, with an excellent correlation of 0.917. The preoperative RLV were matched with the 2-day postoperative RLV showing a significant difference (p = 0.0301). The resected volumes using both techniques (871 and 832 mL) were compared with the resected specimen volume (670 mL), showing a significant difference (p < 0.001) but a high degree of correlation (r = 0.874).

Conclusion

The 3D virtual surgical planning software is accurate and reliable in determining the total liver and future remnant liver volumes. This technique demonstrates a good correlation with the manual technique. Future work will be required to confirm these findings and to evaluate the clinical value of the three-dimensional planning platform.     

Perioperative outcomes of laparoscopic and robot-assisted major hepatectomies: an Italian multi-institutional comparative study

Background

Laparoscopic major hepatectomy (LMH), although safely feasible in experienced hands and in selected patients, is a formidable challenge because of the technical demands of controlling hemorrhage, sealing bile ducts, avoiding gas embolism, and maintaining oncologic surgical principles. The enhanced surgical dexterity offered by robotic assistance could improve feasibility and/or safety of minimally invasive major hepatectomy. The aim of this study was to compare perioperative outcomes of LMH and robotic-assisted major hepatectomy (RMH).

Methods

Pooled data from four Italian hepatobiliary centers were analyzed retrospectively. Demographic data, operative, and postoperative outcomes were collected from prospectively maintained databases and compared.

Results

Between January 2009 and December 2012, 25 patients underwent LMH and 25 RMH. The two groups were comparable for all baseline characteristics including type of resection and underlying pathology. Conversion to open surgery was required in one patient in each group (4 %). No difference was noted in operative time, estimated blood, and need for allogenic blood transfusions. Intermittent pedicle occlusion was required only in LMH (32 % vs. 0; p = 0.004). Length of hospital stay, including time spent in intensive care unit, was similar between the two groups, but patients undergoing LMH showed quicker recovery of bowel activity, with shorter time to first flatus (1 vs. 3 days; p = 0.023) and earlier tolerance to oral liquid diet (1 vs. 2 days; p = 0.001). No difference was noted in complication rate, 90-day mortality, and readmission rate.

Conclusions

This retrospective multi-institution study confirms that selected patients can safely undergo minimally invasive major hepatectomy, either LMH or RMH. The fact that intermittent pedicle occlusion could be avoided in RMH suggests improved surgical ability to deal with bleeding during liver transection, but further studies are needed before any final conclusion can be drawn.     

Clinical evaluation of hyponatremia and hypovolemia in critically ill adult neurologic patients: contribution of the use of cumulative balance of sodium

Purpose

Knowledge of the cumulative balance of sodium (CBS) is important for the diagnosis of salt disorders and water homeostasis and has the potential to predict hypovolemic status in acute neurological patients. However, an extensive application of the use of CBS is still lacking in the intensive care setting, where salt and water homeostasis represents a priority.

Methods

Records of consecutive series of acute neurological patients admitted to a neurointensive care unit over a 6-month period were retrospectively reviewed. CBS was calculated at the admission to the Emergency Department. Discrimination between cerebral salt-wasting syndrome (CSWS) and the syndrome of inappropriate antidiuretic hormone secretion (SIADH) was performed on the basis of the classical criteria. Additionally, we used the findings of a negative CBS exceeding 2 mEq/kg for the diagnosis of CSWS. Two independent clinicians who were blinded to the CBS results performed diagnosis of the causes of hyponatremia and estimated the daily volemic status of the patients on the basis of clinical parameters. Logistic regression analysis was used to determine the independent prognostic factors of hypovolemia.

Results

Thirty-five patients were studied for a total of 418 days. Four patients (11.4 %) fitted the criteria of CSWS and three patients (8.5 %) had SIADH. The unavailability of the CBS led to a wrong diagnosis in three of the eight hyponatremic patients (37.5 %). The risk of developing hypovolemia in patients with negative CBS was 7.1 times higher (CI 3.86–13.06; p < 0.001). Multivariate analysis revealed that negative cumulative fluid balance, negative CBS >2 mEq/kg, and CVP ≤5 cmH₂O were independent prognostic factors for hypovolemia.

Conclusions

CBS is likely to be a useful parameter in the diagnosis of CSWS and a surrogate parameter for estimating hypovolemia in acute neurological patients.