'Brain death': should it be reconsidered?

OBJECTIVE: To evaluate whether current clinical criteria and confirmatory tests for the diagnosis of 'brain death' satisfy the requirements for the irreversible cessation of all functions of the entire brain including the brainstem. DATA SOURCES: Medical, philosophical and legal literature on the subject of 'brain death'. DATA EXTRACTION/SYNTHESIS: We present four arguments to support the view that patients who meet the current operational criteria of 'brain death' do not necessarily have the irreversible loss of all brain (or brainstem) functions. First, many clinically 'brain-dead' patients maintain residual vegetative functions that are mediated or coordinated by the brain or the brainstem. Second, it is impossible to test for any cerebral function by clinical bedside exam, because the tracts of passage to and from the cerebrum through the brainstem are destroyed or nonfunctional. Furthermore, since there are limitations of clinical assessment of internal awareness in patients who otherwise lack the motor function to show their awareness, the diagnosis of 'brain death' is based on an unproved hypothesis. Third, many patients maintain several stereotyped movements (the so-called complex spinal cord responses and automatisms) which may originate in the brainstem. Fourth, not one of the current confirmatory tests has the necessary positive predictive value for the reliable pronouncement of human death. CONCLUSION: According to the above arguments, the assumption that all functions of the entire brain (or those of the brainstem) in 'brain-dead' patients have ceased, is invalidated. Reconsideration of the current concept of 'brain death' is perhaps inevitable.     

Asymptomatic osteonecrosis: should it be treated?

Currently, there is no consensus regarding the treatment of precollapse osteonecrosis, particularly for asymptomatic osteonecrosis. With approximately 10,000 to 20,000 new cases of osteonecrosis a year, no single surgeon or center has the kind of experience that is able to address the most important questions concerning this disease. The literature strongly documents that symptoms of osteonecrosis will progress. Although the literature also supports the progression of asymptomatic osteonecrosis to symptomatic osteonecrosis on to collapse, that support is less convincing. Progression is proportional to lesion size, with small lesions (< 15% of femoral head involvement by volume) unlikely to progress. Although the results of core decompression have been somewhat controversial, the weight of the literature supports both the efficacy and safety of the procedure. The decision to treat osteonecrosis with core decompression is primarily based upon lesion size and stage of disease and does not necessarily depend on whether the patient is symptomatic. As large lesions (> 30% of the femoral head) are less likely to be successfully treated by core decompression and small lesions (< 15% of the femoral head) are less likely to progress, asymptomatic lesions within these ranges can be observed. The literature supports the position that moderately sized lesions (15-30% of the femoral head) should be treated by core decompression (with or without bone grafting).     

Fluoroscopically assisted thromboembolectomy: should it be routine?

The treatment of acute limb ischemia secondary to thromboembolic disease has become significantly more difficult because of the increased proportion of elderly patients presenting with complex patterns of atherosclerotic disease. The presence of multiple medical comorbidities also complicates operative and perioperative management in these patients. Neither the techniques nor catheter designs have changed significantly since the introduction of the balloon embolectomy catheter in 1963, which permitted extraction of clot from remote sites. The authors believe that the use of intraoperative fluoroscopy and the performance of fluoroscopically assisted thromboembolectomy (FATE) greatly improves the results of this treatment in many cases. FATE facilitates catheter passage through tortuous, diseased arteries, identifies residual thrombus and underlying lesions, reduces vessel damage caused by balloon overinflation, and decreases the risk of catheter-induced dissection or atherosclerotic plaque displacement. Intraoperative fluoroscopy helps determine the need for as well as guides adjunctive procedures such as angioplasty and stenting. Such procedures can be performed at the time of the thromboembolectomy simplifying and expediting treatment.     

Autologous iliac crest bone graft: should it still be the gold standard for treating nonunions?

Nonunion is a common complication following long-bone fracture, with a prevalence that ranges from 2.5-46%, depending on the location and severity of the injury to the bone, soft tissue, and vascular structures. The treatment of nonunions involves addressing the biology of fracture repair and the mechanical stability of fracture fixation, which are interrelated. Nonunion treatment has traditionally included the addition of autograft from the iliac crest to enhance healing. However, there an associated morbidity with the harvesting of the graft, and alternatives such as bone marrow aspirate, platelet-rich plasma, allograft, and ceramics have also been studied. In addition, new advances in the understanding of the cellular and molecular mechanisms of fracture repair have led to the use of growth factors, such as bone morphogenetic proteins, to accelerate bone healing. This article reviews the benefits of iliac crest bone graft relative to those of other modalities in the treatment of nonunions.     

The surgical stress response: should it be prevented?

Postoperative complications such as myocardial infarction, pulmonary infection, thromboembolism and fatigue are probably related to increased demands, hypermetabolism, catabolism and other physiologic changes included in the global "surgical stress response." Strategies have been developed to suppress the detrimental components of the stress response so as to improve postoperative outcome. Of the various techniques to reduce the surgical stress response, afferent neural blockade with regional anesthesia to relieve pain is the most effective, although not optimal. Data from numerous controlled clinical trials have demonstrated a reduction in various aspects of postoperative morbidity by such a nociceptive blockade. Although a causal relationship has still to be demonstrated, these findings strongly argue the concept of "stress-free anesthesia and surgery" as an important instrument in improving surgical outcome.     

Pancreatic resection in elderly patients: should it be denied?

Background

Surgery remains the only potential curative therapy for pancreatic cancer, but compromised physiological reserve and comorbidities may deny pancreatic resection from elderly patients.

Methods

The medical records of all patients who underwent pancreatic resection at our institution (2005–2012) were retrospectively reviewed. Postoperative and long-term outcomes were compared between patients with cutoff age of 70 years.

Results

A total of 228 (66 %) and 116 (34 %) patients were <70 and ≥70 years, respectively. Elderly group had worse ASA scores (P?<?0.0001) with higher rates of invasive malignant pathologies (75 vs. 67 %, P?=?0.14), mainly pancreatic ductal adenocarcinoma (58.6 vs. 44.7 %, P?=?0.01). The most common type of resection was pancreaticoduodenectomy (PD) (59 %), followed by distal pancreatectomy (19.8 %). Mean hospital stay was comparable. Elderly patients had less grade ≥IIIb postoperative complications (12 vs. 20.1 %; P?=?0.04) and higher postoperative mortality rates (12.9 vs. 3.9 %; P?=?0.04). In multivariable Cox proportional hazards model for postoperative mortality, age ≥70 years (HR, 3.5; 95 % CI, 1.3–9.3), pancreaticoduodenectomy (HR, 12.6; 95 % CI, 1.6–96), and intraoperative blood loss were significant (P?=?0.012; P?=?0.015, and P?=?0.005, respectively). The overall 5-year survival rates for all patients, for patients aged <70 and ≥70 years were 56, 55, and 41 %, respectively (P?=?0.003).

Conclusions

Elderly patients are at higher risk of mortality after pancreatic resection than usually reported case series. Nonetheless, elderly patients can undergo pancreatic resection with acceptable 5-year survival results. Our results contribute for a better, informed decision-making for elderly patients and their family.     

Anaesthesia and breast-feeding: should breast-feeding be discouraged?

Until a few years ago an interruption of breast-feeding for 12 or even 24 hours was recommended for breast-feeding mothers after anaesthesia, this is no longer valid. If it is the mother's wish, if she is sufficiently awake and physically able, there is no reason not to start breast-feeding a mature and healthy baby immediately after recovery from a general or regional anaesthesia. Even breast-feeding after a Caesarean delivery with administration of the common anaesthetics in the usual (single) doses is no longer considered to be a problem since the amount of the substance taken up from colostrum is vanishingly small in comparison to the amount that is transferred by transplacental routes. Neither the pharmacological properties of the drugs used in association with anaesthesia nor clinical experience justify an interruption of breast-feeding.     

Laser vaporization of the prostate: all as it should be?

Laser vaporization of the prostate currently occupies a prominent place among the surgical options for treatment of benign prostatic syndrome. Particularly the so-called GreenLight laser vaporization with the KTP (80 W) or LBO (120 W) laser has become remarkably widespread throughout the world. There are already 100 of these GreenLight laser systems in use in Germany alone. The introduction of a separate DRG for "laser vaporization" is expected to further increase the significance of this surgical technique. The aim of this study is to evaluate laser vaporization as a whole and to identify possible differences between the different lasers.