Changes in pulmonary function test and cardio-pulmonary exercise capacity in COPD patients after lobar pulmonary resection.

OBJECTIVE: Pulmonary Function Tests (PFT) and Cardio-Pulmonary Exercise Testing (C-PET) are useful to evaluate operability in functionally compromised patients. Although modifications of PFT and C-PET after lung surgery have been widely explored, little information exists as to modifications of exercise capacity in COPD patients undergoing lung resection. We prospectively analyzed the changes in PFT and C-PET in patients with COPD after a pulmonary lobar resection. METHODS: From January 2003 to March 2004 all patients scheduled for lung resection were considered for participation in the study protocol. Those patients with a preoperative diagnosis of COPD on PFT were explored through a C-PET. Only patients who had undergone a lobar pulmonary resection were subsequently considered; these patients had a new complete cardio-respiratory evaluation 3 months after surgery. The pre- and postoperative values compared were those of FEV1, TLC, DLCO, VO2max, and VE/VCO2. Data are expressed as mean +/- standard deviation (SD). Statistic evaluation was made using the Wilcoxon test. RESULTS: During this period 11 patients completed the study protocol. Ten patients underwent surgery for NSCLC and one for a pulmonary aspergilloma. Nine lobectomies and two bilobectomies were performed. In the study population, the preoperative mean value of FEV1 resulted as being 53% (SD+/-20) of the predicted mean value, that of TLC 120% (SD+/-35) and that of DLCO 65% (SD+/-27). The preoperative mean value of VO2max resulted as being 17.8 ml/Kg/min (SD+/-3.25) and mean VE/VCO2 resulted as being 35.7 (SD+/-4). Three months after surgery the measured mean value of FEV1 was 53% (SD+/-18), that of TLC was 99% (SD+/-24) and that of DLCO 52% (SD+/-18). The mean value of VO2max resulted as being 14.1 ml/Kg/min (SD+/-3.04) and that of VE/VCO2 was 42.5 (SD+/-12.8). Statistical analysis of PFT values showed that FEV1 and DLCO were not significantly modified (P > 0.05); in contrast, TLC had significantly decreased (P = 0.008). VO2max had significantly decreased (P = 0.004) and VE/VCO2 had significantly increased (P = 0.018). CONCLUSIONS: Three months after a lobar pulmonary resection, patients with COPD were found to have a significant decrease in exercise tolerance. PFT alone can underestimate the postoperative loss of exercise capacity through exercise.     

Professor Giuseppe Satta,MD 1942–1994 Associate Editor European Journal of Epidemiology

Obituary

Professor Giuseppe Satta, MD 1942–1994 Associate Editor European Journal of Epidemiology     

Prospective randomized trial of low-pressure pneumoperitoneum for reduction of shoulder-tip pain following laparoscopy

BACKGROUND: Postoperative shoulder-tip pain occurs frequently following laparoscopic cholecystectomy. The aim of this randomized clinical trial was to evaluate the efficacy of a low-pressure carbon dioxide pneumoperitoneum during laparoscopic surgery in reducing the incidence of postoperative shoulder-tip pain. METHODS: Ninety consecutive patients undergoing laparoscopic cholecystectomy were randomized prospectively into low-pressure (group A) and normal-pressure (group B) laparoscopic cholecystectomy groups. Patients in group A (n = 46) underwent laparoscopic cholecystectomy with 9 mmHg carbon dioxide pneumoperitoneum during most of the operation, and those in group B (n = 44) had laparoscopic cholecystectomy with 13 mmHg pneumoperitoneum. Shoulder-tip pain was recorded on a visual analogue pain scale 1, 3, 6, 12, 24 and 48 h after operation. RESULTS: The low-pressure pneumoperitoneum did not increase the duration of surgery. There were no significant intraoperative or postoperative complications in either group. Fourteen patients (32 per cent) in group B and five (11 per cent) in group A complained of shoulder pain (P<0.05). Mean shoulder-tip pain scores at 12 and 24 h and postoperative analgesia requirements were also significantly lower in the low-pressure laparoscopic cholecystectomy group (P<0.001). CONCLUSION: A carbon dioxide pneumoperitoneum pressure lower than that usually utilized to perform laparoscopic surgery reduces both the frequency and intensity of shoulder-tip pain following laparoscopic cholecystectomy.     

Pre- and postsurgical psycho-emotional aspects of the orthognathic surgery patient

The current study represents an attempt to examine psychologic changes, emotional impact, expectations, and satisfaction in patients before and after orthognathic surgery. Levels of presurgical anxiety, postsurgical depression, body concept, and all the important changes in physiologic functions were measured by 4 questionnaires, which were self-administered before and after surgery. The results of this study suggest that surgery does, in fact, produce improvements in self-esteem and body image (patient's evaluation of his or her facial attractiveness) and in mastication and speech, and therefore in their lifestyle. All patients experienced a medium to high level of presurgical anxiety, but no major problems after surgery.     

Mitogen-activated protein kinase phosphatase is required for genotoxic stress relief in Arabidopsis

Genotoxic stress activates complex cellular responses allowing for the repair of DNA damage and proper cell recovery. Although plants are exposed constantly to increasing solar UV irradiation, the signaling cascades activated by genotoxic environments are largely unknown. We have identified an Arabidopsis mutant (mkp1) hypersensitive to genotoxic stress treatments (UV-C and methyl methanesulphonate) due to disruption of a gene that encodes an Arabidopsis homolog of mitogen-activated protein kinase phosphatase (AtMKP1). Growth of the mkp1 mutant under standard conditions is indistinguishable from wild type, indicating a stress-specific function of AtMKP1. MAP kinase phosphatases (MKPs), the potent inactivators of MAP kinases, are considered important regulators of MAP kinase signaling. Although biochemical data from mammalian cell cultures suggests an involvement of MKPs in cellular stress responses, there is no in vivo genetic support for this view in any multicellular organism. The genetic and biochemical data presented here imply a central role for a MAP kinase cascade in genotoxic stress signaling in plants and indicate AtMKP1 to be a crucial regulator of the MAP kinase activity in vivo, determining the outcome of the cellular reaction and the level of genotoxic resistance.     

Mini-laparoscopic cholecystectomy vs laparoscopic cholecystectomy

BACKGROUND: We set out to assess the safety and efficacy of mini-laparoscopic cholecystectomy (MLC) in uncomplicated situations. METHODS: MLC was performed on 30 consecutive selected patients (< 60 years old, ASA I-II, uncomplicated cholecystectomy) with one 12-mm and three 3-mm ports. The total operating time, conversion rate, degree of postoperative pain, duration of postoperative hospital stay, complications, and cosmetic results were all reviewed and compared with 30 cases of consecutive conventional laparoscopic cholecystectomy (LC). RESULTS: None of the patients in either group required conversion to open cholecystectomy. No complications were observed. The operating time and duration of hospital stay were similar in both groups. The level of postoperative pain was lower in the MLC group (p < 0.001). More patients in the MLC group expressed satisfaction with the cosmetic result (p < 0.05). CONCLUSIONS: MLC was shown to be feasible in uncomplicated situations. Furthermore, it was associated with less pain and produced better cosmetic results than conventional LC. Randomized studies are still needed to confirm these findings.     

A mobile laminar airflow unit to reduce air bacterial contamination at surgical area in a conventionally ventilated operating theatre

The aim of this study was to evaluate the efficacy of a mobile laminar airflow (LAF) unit in reducing bacterial contamination at the surgical area in an operating theatre supplied with turbulent air ventilation. Bacterial sedimentation was evaluated during 76 clean urological laparotomies; in 34 of these, a mobile LAF unit was added. During each operation, settle plates were placed at four points in the operating theatre (one at the patient area and three at the perimeter), a nitrocellulose membrane was placed on the instrument table and an additional membrane near the wound. During four operations, particle counting was performed to detect particles > or =0.5 microm. Mean bacterial sedimentation on the nitrocellulose membrane on the instrument table was 2730 cfu/m(2)/h under standard ventilation conditions, whereas it decreased significantly to a mean of 305 cfu/m(2)/h when the LAF unit was used, i.e. within the suggested limit for ultraclean operating theatres (P=0.0001). The membrane near the wound showed a bacterial sedimentation of 4031 cfu/m(2)/h without the LAF unit and 1608 cfu/m(2)/h with the unit (P=0.0001). Particle counts also showed a reduction when the LAF unit was used. No significant difference was found at the four points in the operating theatre between samplings performed with, and without, the LAF unit. Use of a mobile LAF unit with turbulent air ventilation can reduce bacterial contamination at the surgical area in high-risk operations (e.g. prosthesis implant).     

Asymptomatic bile duct stones: selection criteria for intravenous cholangiography and/or endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy

OBJECTIVE: Routine use of endoscopic retrograde cholangiography (ERC) and/or intravenous cholangiography (IVC) or magnetic resonance cholangiopancreatography (MRCP) before laparoscopic cholecystectomy (LC) is not cost-effective. The objective of this study was to determine precise and easily applicable criteria to select patients who should undergo IVC, MRCP and/or ERC before LC. DESIGN AND METHODS: Prospectively collected data from 74 consecutive patients who were diagnosed with asymptomatic common bile duct stones (CBDS) before undergoing LC, were compared with data from 74 matched controls without CBDS. Using the chi2 test, those variables were identified which were significantly related to the presence of CBDS. These were inserted into a logistic multiple regression model and, by means of conditional regression analysis, each variable was assigned a score from -2 to +4 proportional to the odds ratio. By adding up the scores obtained, a classification was made as to high, medium and low CBDS risk. RESULTS: As a result, 51 patients were found to be low-risk cases, 53 medium-risk and 44 high-risk. Assuming no further assessment of the bile duct needed to be carried out in low-risk patients, an IVC or MRCP in those at medium risk and an ERC in those at high risk, a calculation was made of the positive predictive value and the sensitivity of the system proposed. The positive predictive value and the sensitivity of the procedure were calculated as being greater than 90%. CONCLUSIONS: This predictive system for the risk of CBDS allows the selective use of ERC, IVC and MRCP to ensure a high yield and improve cost-effectiveness. A controlled prospective study will verify these results.     

Anorectal function problems after left hemicolectomy

BACKGROUND: The aim of this study was to evaluate the subjective anorectal function in patients with left hemicolectomy and to clarify the clinical factors influencing postoperative anorectal function problems. MATERIALS AND METHODS: One hundred and twenty one patients who underwent left hemicolectomy from April 2002 to December 2003 were enrolled in this study and sent questionnaires concerning anorectal function. Left hemicolectomy in patients with cancer was performed by high ligation of the inferior mesenteric artery; in patients with diverticulitis or polyposis, the inferior mesenteric artery was cut just below the branch of the left colonic artery. One hundred patients replied to the questionnaire: 52 men and 48 women, aged 37 to 85, with a mean age of 66.6 years. Differences were analyzed for statistical significance by the Chi square test and by logistic regression. RESULTS: Anorectal function problems was present in 33% of patients: female gender (P = 0.02), laparoscopic surgery (P = 0.04), and postoperative diarrhea (P = 0.04) had significant independent effects on anorectal function problems. Transient early fecal incontinence was observed in 16% of patients and laparoscopic surgery had significant independent effects on this problem (P = 0.04). Inability to discriminate between gas and stool, tenesmus, or urgency were present in 21%, 18%, and 17% of cases, respectively, and were independently associated respectively with laparoscopic surgery (P = 0.005) and postoperative diarrhea (P = 0.019) (P = 0.015). CONCLUSION: In our study the following two issues were clarified: anorectal function problems are frequent after left hemicolectomy, and the laparoscopic technique is linked to poor postoperative anorectal function. The technical methods of high ligation of the inferior mesenteric artery could explain this result.