Index laparoscopic cholecystectomy for acute admissions with cholelithiasis provides excellent training opportunities in emergency general surgery

BackgroundThere is minimal data on the outcome of early laparoscopic cholecystectomy (LC) for acute gallbladder disease when performed by trainees. This study assesses the outcomes of a policy of same admission LC incorporated into a surgical training programme in a major teaching hospital.Methods447 index LCs performed over a 3-year period were reviewed retrospectively. The indications, operating surgeon, operating time, use of IOC, conversion rates, reasons for conversion and post-operative stay were analysed. Multivariate analysis of reasons for conversion was performed.Results150 LCs were performed by consultants and 297 by registrars; 67 were performed by year 1–3 specialist registrars (SpR) and 230 by year 4–6 SpRs. The indications were biliary colic (n = 7), acute cholecystitis (n = 180), chronic cholecystitis (n = 260), carcinoma (n = 1). No difference was found in demographics, operating time (105 min Vs 115 min), use of IOC (34% Vs 29%; P = 0.2) and post–operative stay (2 days Vs 1 day) between consultants and registrars. The conversion rates were higher for consultants compared to registrars (29 (19%) Vs 28 (9%), P = 0.004). The overall conversion rate was 11%. There were no bile duct injuries. Predictors for conversion were CRP > 50 at admission and acute cholecystitis.ConclusionIn a teaching hospital setting most acute admission LCs (66%) were performed by trainees. A step wise training programme with active consultant supervision of all index LCs results in low morbidity, low conversion rates, and a short post-operative stay for acute gallbladder disease. This model of same admission cholecystectomy provides a good training opportunity in emergency general surgery.     

Treadmill versus overground gait training in patients with lower limb burn injury: A matched control study

IntroductionGait impairment is commonly seen in patients with a lower limb burn injury (LLBI). Therefore, the aim of this study was to investigate the effects of two different gait training modes on gait symmetry, functional mobility and kinesiophobia in patients with LLBI.MethodsThis matched control study was conducted between January 2017 and August 2018. Patients with LLBI (n = 28) were allocated to 2 different groups by matching according to burn localization, age, and gender. Group 1 (overground group: n = 14) received overground gait training in addition to standard burn rehabilitation, and Group 2 (treadmill group: n = 14) received treadmill gait training in addition to standard burn rehabilitation. The rehabilitation program and gait training were started when the patient was admitted to the hospital and ended on discharge. These physical therapy interventions were performed 5 days per week. The gait training intensity, including walking speed and duration, was determined according to patient tolerance. Gait parameters, functional mobility, kinesiophobia and pain values were evaluated with GAITRite, the timed up-and-go test (TUG), Tampa Kinesiophobia Scale and Visual Analogue Scale, respectively. These evaluations were made twice; on admission and immediately prior to discharge. Gait symmetry was calculated using the Symmetry Index.ResultsThe baseline characteristics of the groups and initial outcome values were similar. In the comparison of the differences between the overground and treadmill groups, the change in kinesiophobia and TUG values were significantly higher in the treadmill group (p = 0.01, p = 0.02, respectively). The intragroup comparisons showed significant differences in SI in respect of step length (p = 0.004), swing (p = 0.006), stance (p = 0.008) and velocity (p = 0.001), cadence (p = 0.001), TUG (p = 0.001), kinesiophobia (p = 0.001) and pain (p = 0.001) in the overground group. Statistically significant differences were determined in step length (p = 0.01), swing (p = 0.01), stance (p = 0.02) and velocity (p = 0.001), cadence (p = 0.001), TUG (p = 0.001), kinesiophobia (p = 0.001) and pain (p = 0.001) in the treadmill group, when pre and post-training values were compared.ConclusionsThe results of this study have shown that treadmill gait training was more effective in the improvement of functional mobility and reduction in kinesiophobia levels of patients with LLBI compared to overground gait training. Both overground and treadmill gait training also provide greater improvements in the velocity and cadence, and gait symmetry for step length, swing and stance in patients with LLBI.Clinical trial registration numberNCT03217526.     

Omitting pre-operative coagulation screening tests in hip fracture patients: Stopping the financial cascade?

BackgroundCoagulation screening continues as a standard of care in many hip fracture pathways despite the 2011 guidelines from the Association of Anaesthetists of Great Britain and Ireland (AAGBI) which recommend that such screening be performed only if clinically indicated. This study aims to evaluate the use of pre-operative coagulation screening and explore its financial impact.MethodsProspective data was collected in accordance with the “Standardised Audit of Hip Fractures in Europe” (SAHFE) protocol. All patients admitted to our hospital with hip fractures during a 12-month period from November 2011 to November 2012 were analysed. Data including coagulation results and the use of vitamin K or blood products were collected retrospectively from the hospital computer system. Patient subgroup analysis was performed for intraoperative blood loss, post-operative blood units transfused, haematoma formation and gastrointestinal haemorrhage.Results814 hip fractures were analysed. 91.4% (n = 744) had coagulation tests performed and 22.0% (n = 164) had an abnormal result. Of these, 55 patients were taking warfarin leaving 109 patients who had abnormal results and were not taking warfarin. When this group (n = 109) was compared to those who had normal test results (n = 580) and to all other patients (n = 705) there was no difference in intraoperative blood loss (p = 0.79, 0.78), postoperative transfusion (p = 0.38, 0.30), postoperative haematoma formation (p = 0.79, 1.00), or gastrointestinal haemorrhage (p = 0.45, 1.00), respectively. In those who were not taking warfarin, but had abnormal results, none had treatment to reverse their coagulopathy with either vitamin K or blood products. By omitting pre-operative coagulation tests in patients who are not taking warfarin, we estimate a financial saving of between £66,500 and £432,250 per annum.ConclusionsThis study supports the hypothesis that routine pre-operative coagulation screening is unnecessary in hip fracture patients unless they take warfarin or have a known coagulopathy. Moreover, its omission represents significant cost-saving potential.     

Recurrence after laparoscopic high ligation in adolescents: A multicenter international retrospective study of ten hospitals

PurposeInguinal hernia repairs are among the most common operations performed by pediatric surgeons. Laparoscopic high ligation is a popular technique, but its recurrence rate in adolescents is unknown. We hypothesized that recurrence after laparoscopic high ligation in adolescents would be similar to open repair (1.8%–6.3%).MethodsWe evaluated adolescent patients (12–18 years old at the time of surgery) who underwent laparoscopic high ligation across eleven hospitals. At least six months postoperatively, they were contacted by telephone for follow-up. Variables analyzed included demographics, operative details, recurrence, and other complications.ResultsA total of 144 patients were enrolled. One hospital (n = 9) had a recurrence rate of 44.4%, compared to 3.0% (4/135) for the other hospitals. By accounting for 50.0% of recurrences, it represented a statistical outlier and was excluded, leaving 135 patients for analysis. The median age was 14 years, and 63.7% were male. Recurrence with the excluded center was 5.6% (8/144). Use of absorbable suture (OR 42.67, CI 4.41–412.90, p < 0.01) and braided suture (OR 12.10, CI 1.54–95.25, p = 0.02) was weakly associated with recurrence. Recurrence was not significantly different from published results.ConclusionLaparoscopic high ligation of adolescent inguinal hernias has a recurrence rate similar to open repair when performed by experienced surgeons.Type of studyPrognosis study (retrospective study)Level of evidenceLevel II     

Peribulbar versus sub-Tenon block in cardiac patients undergoing cataract surgery during warfarin therapy

ObjectiveTo compare sub-Tenon’s block with peribulbar block in patients on oral warfarin therapy undergoing cataract surgery.Materials and methodsWe studied 100 patients on warfarin undergoing cataract surgery; randomly allocated into one of two groups; sub-Tenon’s group (group S, n = 50), and peribulbar group (group P, n = 50). In group (S), sub-Tenon’s injection of 3–5 ml of anesthetic agent was done using a 25 mm sub-Tenon’s cannula. In group (P), the peribulbar block with 3–4 ml of 2% lidocaine–hyaluronidase (10 IU/ml) and 0.5% bupivacaine was done. Pain and akinesia and postoperative complications were assessed.ResultsSub-Tenon group showed significantly higher frequency of hemorrhage compared to peribulbar group (30% versus 8%, p = 0.041), mainly of grade I. The two groups had comparable frequency of subconjunctival hemorrhage (p = 1.000). No patients experienced sight-threatening hemorrhagic complications. Pain was significantly lower in the sub-Tenon group. Akinesia was significantly better (p = 0.025) 2 min after injection and comparable from 4 to 10 min after injection in the peribulbar group. The majority of patients in the two groups reported satisfaction (p = 0.372). The surgeon expressed higher satisfaction with peribulbar block (94%) compared to sub-Tenon’s block (81%) (p = 0.064).ConclusionPeribulbar and sub-Tenon techniques were relatively safe in patients on anticoagulants during cataract operation. We recommend peribulbar technique owing to significantly less bleeding and more satisfactory akinesia response and hence surgeon comfort.     

Potential efficacy of sensorimotor exercise program on pain,proprioception, mobility,and quality of life in diabetic patients with foot burns: A 12-week randomized control study

BackgroundBoth diabetes mellitus (DM) and burn injuries lead to physical and psychological impairments. Foot burns are still a challenging health condition because of its important sensory role. No previous studies have assessed the physical therapy intervention on diabetic patients with foot burns. Therefore, this study aimed to assess the potential efficacy of sensorimotor exercise on pain, proprioception, mobility, balance, and quality of life in diabetic patients with foot burns.MethodsBetween July 2019 and February 2020, thirty-three diabetic patients with foot burns, aged 32 to 46 yrs, were enrolled in this randomized control study, and randomized consecutively into two groups, study group (n = 16) and control group (n = 17). The study group underwent a sensorimotor exercise program thrice a week for 12 consecutive weeks, however the control group did not undergo the exercise intervention. Both groups were instructed to conduct home exercises. Visual analogue scale (VAS), proprioceptive responses, time-up and go (TUG) values, and short form-36 (SF-36) have been assessed prior and subsequent to the study intervention.ResultsNo significant differences were observed between groups regarding baseline data (p ? 0.05). Subsequent to 12 wk intervention, the study group showed significant improvements in outcome measures (proprioceptive responses, p ? 0.05, VAS, p ? 0.001, TUG, p = 0.003, and SF-36, p ? 0.001) and the control group exhibited significant changes in VAS and SF-36 (p = 0.004, p = 0.043 respectively) however, no significant changes were found in proprioceptive responses and TUG values (p ? 0.05). Between groups, the post-intervention comparison demonstrated statistical differences with tending toward the study group (proprioceptive responses, p ? 0.05, VAS, p ? 0.001, TUG, p = 0.013, and SF-36, p = 0.046).ConclusionsSensorimotor exercise training may improve, pain, proprioceptive responses, mobility, balance, and quality of life in diabetic patients with foot burns. Physiotherapists and rehabilitation providers should include the sensorimotor exercise in their protocols in the treatment of diabetic patients with foot burns.     

Oncological outcomes of laparoscopic nephroureterectomy with pluck method for distal ureter resection

ObjectiveTo report the oncologic outcomes of upper tract urothelial carcinoma treated with laparoscopic nephroureterectomy and pluck method for distal ureter resection.Materials and methodsBetween May 2004 and November 2015, 118 patients with upper urinary tract urothelial carcinoma received laparoscopic radical nephroureterectomy with endoscopic bladder cuff excision at our institution. The medical records were reviewed retrospectively for clinical and pathological results. Cox regression analyses were performed on factors related to oncological outcomes.ResultsThe median follow-up was 26 months. Bladder recurrence was found in 27 patients (22.9%), extravesical retroperitoneal recurrence in four patients (3.4%), and metastases in 17 patients (14.4%). Multivariate analyses showed that male sex was associated with higher bladder recurrence [odds ratio (OR) = 2.2; 95% confidence interval (CI), 1.02–4.78; p = 0.045)], tumor size had significant correlation with locoregional recurrence (OR = 1.29; 95% CI, 1.07–3.43; p = 0.029), tumor stage was significantly correlated with subsequent metastasis (OR = 2.08; 95% CI, 1.21–3.56; p = 0.008) and overall survival (OR = 1.84; 95% CI, 1.06–3.22 ; p = 0.031), and tumor size correlated significantly with cancer-specific survival (OR = 2.57; 95% CI, 1.16–5.72; p = 0.021).ConclusionsTumor size and tumor stage were significantly associated with survival (cancer-specific and overall survival) in patients receiving nephroureterectomy with pluck method.     

Gaining Consent for Carotid Surgery: A Simulation-Based Study of Vascular Surgeons

AimDespite no formal training in consenting patients, surgeons are assumed to be competent if they are able to perform an operation. We tested this assumption for carotid endarterectomy (CEA).MethodsThirty-two surgeons [Group 1: junior surgical trainees – performed 0 CEA's (n = 11); 2: senior vascular trainees – 1–50 CEA's (n = 11); 3: consultant vascular surgeons – > 50 CEA's (n = 10)] consented two patients (trained actors) for a local anaesthetic CEA. The performance was assessed at post hoc video review by two independent assessors using a validated rating scale and checklist of risk factors.ResultsThere was no difference in performance between the junior and senior trainees (1: median 91 range 64–121; 2: median 100.5 range 66–125; p = 0.118 1 vs. 2 Mann–Whitney). There was a significant improvement between senior trainees and consultant surgeons (3: median 120 range 89–1 142; p = 0.001 2 vs. 3). Few junior (1/11) and senior (2/11) trainees, and most (8/11) consultants, were competent. Inter-rater reliability was high (α = 0.832).Consultant surgeons were significantly more likely to discuss cranial nerve injuries (p < 0.0001 Chi-square test) as well as personal or hospital specific stroke risk (p < 0.0001) than their junior counterparts. They were less likely to discuss infection (p < 0.0001).ConclusionSenior trainees, despite being able to perform a CEA, were not competent in consent. The majority of consultant surgeons had developed competence in consenting even though they had no formal training.     

Prehospital fast track care for patients with hip fracture: Impact on time to surgery,hospital stay,post-operative complications and mortality a randomised,controlled trial

IntroductionAmbulance organisations in Sweden have introduced prehospital fast track care (PFTC) for patients with suspected hip fracture. This means that the ambulance nurse starts the pre-operative procedure otherwise implemented at the accident & emergency ward (A&E) and transports the patient directly to the radiology department instead of A&E. If the diagnosis is confirmed, the patient is transported directly to the orthopaedic ward. No previous randomised, controlled studies have analysed PFTC to describe its possible advantages.The aim of this study is to examine whether PFTC has any impact on outcomes such as time to surgery, length of stay, post-operative complications and mortality.MethodsThe design of this study is a prehospital randomised, controlled study, powered to include 400 patients. The patients were randomised into PFTC or the traditional care pathway (A&E group).ResultsTime from arrival to start for X-ray was faster for PFTC (mean, 28 vs. 145 min; p < 0.001), but the groups did not differ with regard to time from start of X-ray to start of surgery (mean 18.40 h in both groups). No significant differences between the groups were observed with regard to: time from arrival to start of surgery (p = 0.07); proportion operated within 24 h (79% PFTC, 75% A&E; p = 0.34); length of stay (p = 0.34); post-operative complications (p = 0.75); and 4 month mortality (18% PFTC, 15% A&E p = 0.58).ConclusionPFTC improved time to X-ray and admission to a ward, as expected, but did not significantly affect time to start of surgery, length of stay, post-operative complications or mortality. These outcomes were probably affected by other factors at the hospital. Patients with either possible life-threatening conditions or life-threatening conditions prehospital were excluded.     

Short-Term Results of A Randomized Trial Comparing Remote Endarterectomy and Supragenicular Bypass Surgery for Long Occlusions of the Superficial Femoral Artery [The REVAS Trial]

ObjectiveTechniques for surgical repair of Trans-Atlantic Inter-Society Consensus (TASC) C and D lesions of the superficial femoral artery (SFA) are supragenicular bypass grafting or the less invasive remote endarterectomy (RSFAE). This trial compares the patency rates of both techniques.DesignRandomized, multicenter trial.Materials and methods116 patients were randomized to RSFAE (n = 61) and supragenicular bypass surgery (n = 55). Indications for surgery were claudication (n = 77), rest pain (n = 21), or tissue loss (n = 18).ResultsMedian hospital stay was 4 days in the RSFAE group compared with 6 days in the bypass group (p = 0.004). Primary patency after 1-year follow-up was 61% for RSFAE and 73% for bypass (p = 0.094). Secondary patency was 79% for both groups. Subdividing between venous (n = 25) and prosthetic grafts (n = 30) shows a primary patency of 89% and 63% respectively at 1-year follow-up (p = 0.086).ConclusionRSFAE is a minimally invasive adjunct in the treatment of TASC C and D lesions of the SFA, with shorter admittance and a comparable secondary patency rate to bypass. The venous bypass is superior to both RSFAE and PTFE bypass surgery, but only 45% of patients had a sufficient saphenous vein available.This study is registered with ClinicalTrials.gov, number NCT00566436.     

Long-term follow-up of trauma patients before and after implementation of a physician-staffed helicopter: A prospective observational study

IntroductionThe first Danish Helicopter Emergency Medical Service (HEMS) was introduced May 1st 2010. The implementation was associated with lower 30-day mortality in severely injured patients. The aim of this study was to assess the long-term effects of HEMS on labour market affiliation and mortality of trauma patients.MethodsProspective, observational study with a maximum follow-up time of 4.5 years. Trauma patients from a 5-month period prior to the implementation of HEMS (pre-HEMS) were compared with patients from the first 12 months after implementation (post-HEMS). All analyses were adjusted for sex, age and Injury Severity Score.ResultsOf the total 1994 patients, 1790 were eligible for mortality analyses and 1172 (n = 297 pre-HEMS and n = 875 post-HEMS) for labour market analyses. Incidence rates of involuntary early retirement or death were 2.40 per 100 person-years pre-HEMS and 2.00 post-HEMS; corresponding to a hazard ratio (HR) of 0.72 (95% confidence interval (CI) 0.44–1.17; p = 0.18). The HR of involuntary early retirement was 0.79 (95% CI 0.44–1.43; p = 0.43). The prevalence of reduced work ability after three years were 21.4% vs. 17.7%, odds ratio (OR) = 0.78 (CI 0.53–1.14; p = 0.20). The proportions of patients on social transfer payments at least half the time during the three-year period were 30.5% vs. 23.4%, OR = 0.68 (CI 0.49–0.96; p = 0.03). HR for mortality was 0.92 (CI 0.62–1.35; p = 0.66).ConclusionsThe implementation of HEMS was associated with a significant reduction in time on social transfer payments. No significant differences were found in involuntary early retirement rate, long-term mortality, or work ability.     

The impact of serum albumin and serum protein levels on POSSUM score of patients with proximal femur fractures

BackgroundPOSSUM was developed to predict risk-adjusted mortality and morbidity rates for surgical procedures. We evaluated the impact of serum albumin and serum protein levels on POSSUM scores.MethodsMedical files of 2269 patients operated for proximal femur fractures were reviewed. Preoperative serum albumin levels were available for 387 patients (mean 35.1 g/l, range 22–49) and serum protein levels for 279 patients (mean 61.6 g/l, range 40–86).ResultsSerum albumin and protein levels were inversely associated with mortality in multivariate models (albumin, OR = 0.89, p = 0.009; protein, OR = 0.92, p = 0.009) and in composite outcome models as well (albumin, OR = 0.955, p = 0.219, protein, OR = 0.94, p = 0.014). The area under the curve (AUC) for POSSUM prediction of mortality (n = 1770) was 0.632 (95% CI: 0.580–0.684, p < 0.001). The AUC for a model including serum protein levels was 0.742 (95% CI: 0.649–0.834, p < 0.001). Hospitalisation time was longer for patients with lower serum proteins levels (p = 0.045), with an inverse correlation (Pearson correlation −0.164, p = 0.011).ConclusionsLower preoperative serum albumin and serum protein levels were associated with increased risk for mortality, increased hospitalisation time and poorer outcomes in patients operated for proximal femoral fractures. Including those values to POSSUM scores would increase their predictive power.     

Results after gastrocnemius recession in 73 patients

BackgroundVery few studies describe the clinical results and complications following the surgical procedure of gastrocnemius recession.PurposeTo survey the patient reported outcomes in patients operated with gastrocnemius recession as single procedure for various foot conditions.Material and methods93 patients operated with gastrocnemius recession as single procedure between 2006 and 2011 were detected in the database. 73 patients responded to the invitation for study participation. Questionnaires containing patient reported satisfaction, complications, plantar flexion power and visual analog pain score were used for evaluation of the postoperative result.Results45/73 (62%) patients reported a good or excellent result. 8/73 (11%) patients reported a significant postoperative complication. 16/73 (22%) patients noted reduced or severely reduced plantar flexion power after surgery. VAS pain score significantly decreased from 7.0 before surgery to 1.8 (p =0.015) after surgery for patients with plantar fasciitis (n =18) and from 5.6 to 2.3 (p < 0.01) for patients with metatarsalgia (n = 28).ConclusionPatients treated with gastrocnemius recession for plantar fasciitis demonstrated good clinical results. The complication rate was higher than reported by others.     

Breast cancer in women under 40 years of age: A series of 57 cases from Northern Ireland

BackgroundThere are few studies examining breast cancer in women under the age of 40 years, particularly in western European populations. Such tumours are reported to be more aggressive, possibly due to a different pathophysiology compared to older patients.MethodsWe performed a retrospective review of all women less than 40 years of age, diagnosed or treated with breast cancer, from June 2001 to June 2007 to assess pathophysiological factors that may influence clinical outcome and prognosis including patient demographics, clinical presentation, pre-operative investigations, surgical and pathological findings, treatment and outcome.ResultsFifty-eight women (mean age 34.9 years, range 27–39 years) were identified. One patient was excluded due to incomplete data; 98.2% (n = 56) patients presented directly to our symptomatic clinic; 89.5% (n = 51) patients had a palpable lump; 71.9% (n = 41) patients had no family history. Mammography was less sensitive than ultrasound (64.3% vs. 82.4%) while fine needle aspiration cytology was 92.5% sensitive for malignancy. Twenty-nine (50.9%) patients underwent breast-conserving surgery (BCS) of which 7 proceeded subsequently to completion mastectomy due to involved margins. Twenty-six (45.6%) patients required total mastectomy primarily while 2 (3.5%) patients were treated palliatively due to metastatic disease. The mean tumour size (nearest resection margin) was 2.13 cm (2.58 mm) for BCS and 3.95 cm (6.38 mm) for mastectomy. From a total of 55 primary resections, 85.5% (n = 47) of tumours were invasive ductal carcinoma; 57.4% (n = 31) and 40.7% (n = 22) were grade II and III tumours respectively. Lymphovascular invasion was identified in 50.9% (n = 28) while 40.0% (n = 22) were lymph node positive for metastatic disease. 76.8% (n = 43), 39.3% (n = 22) and 30.2% (n = 16) were oestrogen, progesterone and human epidermal growth factor receptor-2 positive respectively. The mean Nottingham prognostic index was 4.37 (range 2.2–8.4). Neo-adjuvant and adjuvant chemotherapy was administered to 9.3% (n = 5) and 80.0% (n = 44) of surgically treated patients respectively while 76.4% (n = 42) patients received adjuvant radiotherapy. 76.4% (n = 42) of patients were treated with tamoxifen. Four patients received Herceptin® therapy. Statistically significant univariate factors adversely associated with overall survival were time from referral to out-patient department attendance (p = 0.038), administration of neo-adjuvant treatment (p = 0.019), surgical intervention (p < 0.001), progesterone receptor positivity (p = 0.018) and tumour recurrence (p < 0.001). 86.0% (n = 49) patients were alive at mean follow-up of 52 months; 82.5% (n = 47) remain disease free.ConclusionOur study reports a low familial trait rate combined with a high proportion of hormonally active tumours less than grade III which suggests that breast cancer in this series of young women from Northern Ireland may be less aggressive and more hormonally responsive than anticipated.     

Endovascular Repair of the Thoracic Aorta: Predictors of 30-Day Mortality in Patients on the New Zealand Thoracic Aortic Stent Database (NZ TAS)

ObjectivesTo evaluate data in the New Zealand Thoracic Aortic Stent database to try and identify a scoring system that could predict 30-day mortality in patients undergoing stenting of the descending thoracic aorta (TEVAR).DesignRetrospective analysis of the New Zealand thoracic aortic stent database between December 2001 and August 2007.Materials and methodsThe 30-day mortality of the 122 patients is 7.38% (n = 9). Risk factors were recorded based on the Society of Thoracic Surgeons (STS) risk score. Glasgow aneurysm score was calculated and the pathology being treated analysed. Univariate analyisis was carried out.ResultsThe mortality of three pathology groups was compared. 30-day mortality was 2.04% (n = 1) in the elective aneurysm group, 17.95% (n = 7) in the complicated Stanford type B dissection group, and 0% (n = 0) in the trauma group. Thirty-day mortality is significantly higher in the dissection group compared with the elective aneurysm (p = 0.02) and trauma (p = 0.03) groups. The most frequent risk factors in the dissection group of patients were peripheral vascular disease, smoking and hypertension. Although percentage mortality is higher with increasing GAS, the results are not statistically significant (p = 0.34). No independent risk factors were identified from the STS risk score data.ConclusionNo specific risk score system seems to be able to predict mortality in TEVAR patients.     

Post-operative C-reactive protein profile following abdominal wall reconstruction with transversus abdominis posterior components separation

IntroductionAbdominal wall reconstruction using posterior component separation with transversus abdominis release (AWTAR) produces a unique post-operative CRP profile, when compared to routine elective colorectal operations. Therefore, we aim to establish the normal post-operative C-reactive protein (poCRP) profile following AWRTAR and reduce the unnecessary invasive interventions in patients already at greater risk of septic complications.MethodsA retrospective analysis of daily poCRP levels was performed both for patients who underwent uncomplicated AWRTAR (n = 12), and a comparator group of uncomplicated open right hemicolectomies (RH) matched for age and sex (n = 24). All operations in both groups were performed by a single surgeon from 2013 to 2015.ResultsThe median (IQR) age was 62 (16) and 67 (16) years respectively, with a higher proportion of males to females in both groups (10:2 vs. 17:7). The poCRP profile follows an initial steep rise, peaking at day 2 followed by a gradual washout phase. The poCRP peak is significantly greater in the AWRTAR group compared to the RH group (274 [95%CI ±25] vs. 160 [95%CI ± 27]; p = 0.0001), with a positive correlation between day 2 CRP levels and operative length (r = 0.56).ConclusionsWe have demonstrated that uncomplicated AWRTAR provokes a significantly greater poCRP rise (>200) compared to that well described in the literature for uncomplicated open colectomy. As poCRP is an important marker of post-operative recovery with abnormally high levels associated with septic complications, these data should help clinicians interpret the post-operative clinical course after AWRTAR.     

Influencia del acceso laparoscópico en la mortalidad cáncer-específica de los pacientes con cáncer de vejiga en un estadio pTa-2pN0R0 tratados con cistectomía radical

Introduction and objectiveMinimally invasive surgery represents an attractive surgical approach in radical cystectomy. However, its effect on the oncological results is still controversial due to the lack of definite analyses. The objective of this study is to evaluate the effect of the laparoscopic approach on cancer-specific mortality.Material and methodA retrospective cohort study of two groups of patients in a pT0-2pN0R0 stage, undergoing open radical cystectomy (ORC) (n = 191) and laparoscopic radical cystectomy (LRC) (n = 74). Using Cox regression, an analysis has been carried out to identify the predictor variables in the first place, and consequently, the independent predictor variables related to survival.Results90.9% were males with a median age of 65 years and a median follow-up period of 65.5 (IQR 27.75-122) months. Patients with laparoscopic access presented a significantly higher ASA index (P = .0001), a longer time between TUR and cystectomy (P = .04), a lower rate of intraoperative transfusion (P = .0001), a lower pT stage (P = .002) and a lower incidence of infection associated with surgical wounds (P = .04). When analyzing the different risk factors associated with cancer-specific mortality, we only found the ORC approach (versus LRC) as an independent predictor of cancer-specific mortality (P = .007). Open approach to cystectomy multiplied the risk of mortality by 3.27.ConclusionsIn our series, the laparoscopic approach does not represent a risk factor compared to the open approach in pT0-2N0R0 patients.     

Cisatracurium dose–response relationship in patients with chronic liver disease

ObjectiveCisatracurium is approximately 3 times more potent than atracurium, devoid of histamine release and cardiovascular side effects and mainly eliminated by Hofmann degradation. Patients with liver disease exhibit abnormal response to most of muscle relaxants. This study was designed to evaluate the dose–response of cisatracurium in patients with mild–moderate liver impairment in comparison with healthy subjects.MethodsEighty ASA physical status I–II patients of both sexes, scheduled for elective surgical procedures under general anesthesia, were divided according to their preoperative hepatic status and laboratory investigations into two groups; Group I (control group with normal liver functions, n = 40) and Group II (Liver dysfunction group, Child-Pugh Score A or B, n = 40). The dose–response curve was constructed, ED₅₀ and ED₉₅ were estimated.ResultsThe preoperative laboratory parameters showed statistically significant differences between the two groups regarding serum albumin, total bilirubin, ALT, AST, PT, PC and INR. The operative data showed statistically insignificant difference between the two groups regarding the 1st dose response (p = 0.152), the estimated ED₈₀ (p = 0.886) and the calculated 2nd dose (p = 0.886) and statistically significant differences between the two groups regarding the 2nd dose response (p = 0.006), the measured ED₅₀ (p = 0.010) and the measured ED₉₅ (p = 0.001). In conclusion, the measured ED₅₀ and ED₉₅ through two-dose dose–response curve technique were clinically insignificant from using the single-dose technique. The dose–response curve of cisatracurium in patients with chronic liver disease was clinically insignificant in comparison with healthy subjects.     

Pediatric burn-trauma patients have increased length of stay compared to trauma-only patients: A propensity matched analysis

BackgroundTrauma is the leading cause of mortality in children. Burn injury involves intensive resources, especially in pediatric patients. We hypothesized that among pediatric trauma patients, combined burn-trauma (BT) patients have increased length of stay (LOS) and mortality compared to trauma-only (T) patients.MethodsThe Pediatric Trauma Quality Improvement Program (2014–2016) was queried and BT patients were 1:2 propensity-score-matched to T patients based on age, gender, hypotension on admission, injury type and severity.Results93 BT patients were matched to 186 T patients. There were no differences in matched characteristics. BT patients had a longer median LOS (4 vs 2 days, p < 0.001) with no difference in mortality (1.1% vs 1.1%, p = 1.00), intensive care unit (ICU) LOS (3 vs 3 days, p = 0.55), or complications including decubitus ulcer (0% vs 1.1%, p = 0.32), deep vein thrombosis (0% vs 0.5%, p = 0.48), extremity compartment syndrome (1.1% vs 0%, p = 0.16), and urinary tract infection (1.1% vs 1.1%, p = 1.00).ConclusionPediatric BT patients had twice the LOS compared to a matched group of pediatric T patients. There was no difference between the cohorts in ICU LOS, complications or mortality rate. When evaluating risk-stratified quality metrics such as LOS, concomitant burn injury should be incorporated.     

Association of IL-2RA and IL-2RB genes with erosive status in early rheumatoid arthritis patients (ESPOIR and RMP cohorts)

ObjectivesTo assess the impact of single nucleotide polymorphisms (SNPs) in IL-2RA (rs2104286) and IL-2RB (rs743777 and rs3218253) genes on the risk of erosions in rheumatoid arthritis (RA) patients.MethodsThis work is derived from 2 prospective cohorts of early RA: ESPOIR (n = 439) and RMP (n = 180). The proportions of patients with erosions at baseline and 1 year according to the genotypes of IL2RA (rs2104286) or the haplotypes constructed with the 2 SNPs of IL2RB were compared in the whole population and in ACPA positive patients. A meta-analysis assessing the risk of erosion depending on the haplotypes of the 2 SNPs of IL-2RB was performed using the Mantel-Haenszel method. A multivariate model was used to assess the independent effect of the haplotypes of IL-2RB on the risk of erosions.ResultsThe AC haplotype of IL-2RB carriage was significantly associated with the rate of erosions in ACPA positive patients in ESPOIR cohort (rate of erosions: AC/AC: 78% versus GC or GT/GC or GT: 44%, p = 0.001). A meta-analysis of ESPOIR and RMP cohorts confirmed that the carriage of AC haplotype was significantly associated with the rate of erosions at 1 year in the whole sample (OR[95%CI] = 1.92[1.14–3.22], p = 0.01) and in ACPA positive patients (OR[95%CI] = 3.34[1.68–6.67], p = 0.0006). A multivariate model in ESPOIR cohort demonstrated the independent effect of the carriage of the AC haplotype (6.03[1.94–18.69], p = 0.002) on the risk of erosions in ACPA+ patients.ConclusionA haplotype constructed with 2 SNPs located on IL-2RB gene was associated with erosive status in early RA.