Inhaled milrinone: a new alternative in cardiac surgery?

The administration of milrinone through inhalation has been studied in only a few animal and human studies. Compared to the intravenous administration, inhaled milrinone has been shown to reduce pulmonary artery pressure without systemic hypotension. Therefore, this approach could represent an alternative to nitric oxide. This current state of knowledge of intravenous and inhaled milrinone is presented and summarized.     

Three new tools for parathyroid surgery: expensive and unnecessary?

BACKGROUND: The intraoperative quick parathyroid hormone assay, the intraoperative gamma probe, and endoscopic parathyroidectomy are three very new techniques developed to facilitate parathyroid surgery. Some hospitals do not have the necessary equipment, and many, like ours, continue to operate in the time-honored way. STUDY DESIGN: We performed a retrospective chart review of 34 such operations, done with the use of Sestamibi scans, but entirely without the newer modalities. RESULTS: Four-gland exploration was carried out on all patients. Operative times ranged from 15 to 165 minutes, with a mean of 47 minutes, and incision lengths ranged from 2 to 3 cm, with a mean of 2.8 cm. There was no mortality, no reoperation, and no vocal cord or recurrent laryngeal nerve injury. Our cure rate was 100%, as determined by a fall in postoperative calcium and parathormone levels. CONCLUSIONS: In our view, the intraoperative parathyroid hormone assay, gamma probe, and endoscopic parathyroidectomy add an entirely unnecessary cost to an operation that can be completed satisfactorily with a preoperative Sestamibi scan and a thorough four-gland exploration.     

Laparoscopic adrenalectomy: alternative or new standard?

Laparoscopy has become a standard approach for adrenalectomy because of its safety, low invasiveness, and less demanding technical nature and the readily removable size of tumor through trocar incision. Comparative studies between open and laparoscopic adrenalectomy document less blood loss, shorter hospital stay, and lower incidence of complication. These reports also show that the patients have less pain, use fewer narcotics postoperatively, and have quicker resumption of oral intake after surgery with the laparoscopic approach. The techniques for laparoscopic adrenalectomy started with the transperitoneal approach and developed into the retroperitoneal approach. Further technical development and recognition yielded three transperitoneal and two retroperitoneal approaches. Characteristics of each approach are discussed. Due to technical developments and experiences in laparoscopic surgery, application of the laparoscopic approach has been expanded to include excision for adrenal cancer and laparoscopic partial adrenalectomy for bilateral pheochromocytoma in certain cases and in selected institutes.     

Single access laparoscopic surgery: Complementary or alternative to NOTES?

In recent years, single access laparoscopic surgery (SALS) and natural orifice translumenal endoscopic surgery (NOTES) have gained interest from both clinical and industrial point of view, with the increased development of different laparoscopic instruments, production of various access ports, and improvement of operative endoscopes. The main advantages stimulating these two approaches are the cosmetic result, the rapid recovery of the patient, and the reduced need for pain killers. SALS and NOTES are in part complementary and in part alternative techniques. Currently, SALS is much simpler and technically easier than NOTES.     

Plant extracts: sense or nonsense?

PURPOSE OF REVIEW: To assess the current role of plant extracts in the medical management of lower urinary tract symptoms due to benign prostatic enlargement/benign prostatic obstruction. RECENT FINDINGS: In 2006, two clinical trials meeting the WHO benign prostatic hyperplasia consensus conference criteria (randomized against placebo/standard therapy, study duration 12 months) were published. One trial compared a saw palmetto extract with placebo. This industry-independent trial published in the New England Journal of Medicine was negative, that is, this saw palmetto extract had no effect on symptoms, Qmax and postvoid residual volume. In another trial, a saw palmetto/urtica combination was compared with tamsulosin. After 12 months, the improvement of symptoms was identical in both study arms. No detailed data were presented, however, on Qmax, postvoid residual or prostate volume. The biological mechanisms of plant extracts in vivo are still unknown and the numerous metaanalyses cannot supplement high-quality prospective trials. SUMMARY: Further prospective studies according to WHO benign prostatic hyperplasia standards are required to reliably determine the role of plant extracts in contemporary lower urinary tract symptoms management and to be able to answer the question in the title: 'plant extracts: sense or nonsense?' Plant extracts are currently not recommended by the American and European Association of Urology benign prostatic hyperplasia guidelines.     

Pain disaggregation theory--statistical nonsense or a pointer to a paradigm for quantum nociception?

Background. The various patterns of patients’ experienceof treated acute post-thoracotomy pain exemplify the phenomenonof disaggregation. The intent in this study was to define atheory of disaggregation with a hard-wired neuroanatomical modelof thoracotomy pain. Methods. In order to distinguish the disaggregated nociceptionconducted along one of three possible pathways, the vagus, thephrenic and, in this study, the intercostal nerves, data from143 patients undergoing thoracic surgery, and that from twopreviously conducted studies of multimodal analgesic regimens,were reviewed. The values of one subjective outcome measure(verbal rating score) at different stress levels—at rest,on raising the arm, and on coughing (dynamic pain scores)—wereused to construct individuals’ charts (pain profiles)of the progress of pain relief over time. These were batched,and analysed using statistics of summary measures. Results. This was a crude exercise in the handling of redundantdata, but there is a suggestion that it is possible to distinguisha disaggregated route by an effect of a treatment on a massof nociception. Conclusions. This information could underpin a paradigm of quantumnociception, and has potential to quantify aspects of analgesiapractice and current and future neurophysiological theoriesof pain. Prospective studies are warranted. Br J Anaesth 2003; 91: 279–81     

Regional anesthesia in cardiac surgery: a friend or a foe?

Escalating costs and change in the profile of patients presenting for cardiac surgery requires modification of perioperative management strategies. Regional anesthesia has played an integral part of many fast-track anesthesia protocols across North America and Europe. This review suggests that for patients undergoing coronary artery bypass graft surgery, the risk-to-benefit ratio is in favor of epidural and spinal anesthesia, provided there are no specific contraindications and the guidelines for the use of regional techniques in cardiac surgery are followed. Patients managed with regional techniques seem to benefit from superior postoperative analgesia, shorter postoperative ventilation, reduced incidence of supraventricular arrhythmia, and lower rates of perioperative myocardial infarction. The results of this analysis suggest that for each episode of neurologic complication, 20 myocardial infarctions and 76 episodes of atrial fibrillation would be prevented, thus, we would consider the regional anesthesia and analgesia to be an effective strategy that improves perioperative morbidity. However, other treatment modalities such as the addition of calcium channel blockers, aspirin, and beating heart surgery, are also suggested to be beneficial in cardiac surgical patients and may impose less risk than the use of regional techniques. We believe that the results presented in this review are encouraging enough to permit continued investigation. A prospective, randomized, controlled multicenter trial needs to be adequately powered to answer important clinical questions and allow for a long-term follow-up.