Ischemia-reperfusion injury in the liver during renal transplantation: does perfusion solution play any role?

The effect of ischemia-reperfusion (I/R) injury within a transplanted kidney has not been reported on the liver as a remote organ. One hypothesis is that there is no difference between kidney perfusion solutions regarding antioxidants in liver after an I/R injury. We used four pigs with Ringer's lactate (RL); four with university of Wisconsin (UW); and two in a control (C) group. A liver parenchymal biopsy was obtained before renal artery/vein solution clamping for 20 minutes. Either RL or UW solutions were infused through arterial cannulas for 20 minutes as previously described elsewhere. For the sham group, we used 0.9% NaCl. After reperfusion for 20 minutes, we obtained a second liver parenchymal biopsy. Measurements of superoxide dismutase (SOD), glutathione peroxidase (GP-x), and malondialdehyde (MDA) levels were compared using paired student t tests within groups and analysis of variance between groups. The results were expressed as mean values +/- SEM with P < .05 accepted as significant. Although GP-x, SOD, and MDA decreased after ischemia-perfusion-reperfusion injuries in all groups, except MDA in UW and SOD, and MDA in C groups; only the MDA for C was significant (P = .04) Comparing the groups, GP-x (P = .01) and MDA (P = .003) levels after ischemia-perfusion-reperfusion were significant while changes in SOD levels did not show any difference (P > .05). In a kidney transplantation model, the liver was affected during the ischemia-perfusion-reperfusion process as evidenced by antioxidant enzymes. The pathophysiology and clinical importance of this phenomenon requires further study. Comparing the perfusion solutions, no difference was found between RL and UW regarding their effects to decrease renal I/R injury on the liver in pigs.     

Laparoscopic simulation training: does timing impact the quality of skills acquisition?

Background

Current surgical training involves integration of educational interventions together with service requirements during regular working hours. Studies have shown that voluntary training has a low acceptance among surgical trainees and obligatory simulation training during the regular working week leads to better skill acquisition and retention. We examined the difference in training effectiveness depending on the time of day.

Methods

Surgical novices underwent a curriculum consisting of nine basic laparoscopic tasks. The subjects were permitted to choose a training session between during regular working hours (8:00–16:00) or after hours (16:00–20:00). Each subject underwent baseline and post-training evaluation after completion of two 4-h sessions. Task completion was measured in time (s), with penalties for inaccurate performance. Statistical analysis included matched-pairs analysis (sex, age, and previous operative experience) with χ² und Mann–Whitney U test for between groups and Wilcoxon signed-rank test for testing within one group.

Results

There were no differences in demographic characteristics between the groups. Comparison of the individual baseline and post-training performance scores showed a significant (P < 0.05) improvement for all subjects in all exercises. No significant differences between groups were observed.

Conclusion

All subjects improved in skill significantly throughout the week regardless of the timing of the training intervention. Simulation training can be offered outside of regular working hours with acceptable effectiveness.     

Laparoscopic extraperitoneal aortic dissection: does single-port surgery offer the same possibilities as conventional laparoscopy?

Background

This study aimed to demonstrate the feasibility of single-port surgery (SPS) for laparoscopic extraperitoneal aortic dissection.

Methods

From December 2010 to April 2011, all patients referred for aortic lymph node staging underwent a laparoscopic extraperitoneal approach with a single-port device. The extraperitoneal approach was performed using only one 3–4?cm incision on the left side. Gelpoint from Applied Medical (Rancho Santa Margarita, CA, USA), a 10-mm 0° laparoscope, and 5-mm standard instruments were used.

Results

The study enrolled 13 patients. Aortic dissection was complete for 11 patients and incomplete for 2 patients. The mean lymph node count was 16 (range, 7–40). The mean blood loss was 40.7?ml (range, 0–100?ml), and no transfusion was necessary. The mean hospital stay was 1.7?days (range, 1–4?days) for this series.

Conclusion

The study results demonstrate the feasibility of single-port-access laparoscopy for extraperitoneal aortic lymphadenectomy. The lymph node count was similar to that described in the published experience of conventional laparoscopic extraperitoneal dissection. This preliminary report shows that SPS is usable for extraperitoneal aortic dissection and that it is possible to perform this procedure using only one skin incision compared with the three or four incisions required for conventional laparoscopy.     

Patient blood management during the COVID–19 pandemic: a narrative review

As COVID–19 disease escalates globally, optimising patient outcome during this catastrophic healthcare crisis is the number one priority. The principles of patient blood management are fundamental strategies to improve patient outcomes and should be given high priority in this crisis situation. The aim of this expert review is to provide clinicians and healthcare authorities with information regarding how to apply established principles of patient blood management during the COVID–19 pandemic. In particular, this review considers the impact of the COVID–19 pandemic on blood supply and specifies important aspects of donor management. We discuss how preventative and control measures implemented during the COVID–19 crisis could affect the prevalence of anaemia, and highlight issues regarding the diagnosis and treatment of anaemia in patients requiring elective or emergency surgery. In addition, we review aspects related to patient blood management of critically ill patients with known or suspected COVID–19, and discuss important alterations of the coagulation system in patients hospitalised due to COVID–19. Finally, we address special considerations pertaining to supply-demand and cost-benefit issues of patient blood management during the COVID–19 pandemic.     

Comparison of minimally invasive surgical skills of neurosurgeons versus general surgeons: is there a difference in the first exposure to a virtual reality simulator?

OBJECTIVE: The increasing use of minimally invasive surgery, which has a longer learning curve compared to open surgery lets the necessity to develop training programs to improve endoscopic skills of trainees become ever clearer. The aim of this study was to compare the endoscopic skills of neurosurgeons versus general surgeons at first exposure to a virtual reality simulator. METHODS: 72 general surgeons who visited the 122nd Conference of the German Surgeons Society (DGCH in Munich 2005) and 35 neuroendoscopic surgeons, who visited the Third World Conference of the International Study Group of Neuroendoscopy (ISGNE in Marburg 2005) participated in this study. Each participant performed the basic module "clip application" on the virtual reality simulator (LapSim). All participants were given the same pretest instructions. Time to complete the task, error score and economy of motion were recorded. RESULTS: The general surgeons performed the clip application faster, but with more errors than neuroendoscopic surgeons. However, the difference of both parameters was not significant. Both surgeon groups have a similar score for economy of motion. CONCLUSION: Although neuroendoscopic surgeons were exposed to a foreign procedure and unfamiliar equipment, they were able to perform virtual endoscopy with similar accuracy as general surgeons, who are adapted to these endoscopic instruments and procedures and do these daily.     

Training the novice to become cardiac surgeon: does the “early learning curve” training compromise surgical outcomes?

Objective

It is unclear whether novice trainees can be taught safely to perform adult cardiac surgery without any impact on early or late outcomes.

Methods

All patients (n = 1305) data were obtained from an externally validated, mandatory institutional database (2003–2010). ‘Novice’ is defined as a trainee who required substantial assistance or supervision to perform part or whole of the specified procedure (Intercollegiate Surgical Curriculum Programme UK, Competency Level ≤2). Outcome measures were in-hospital mortality, composite score of in-hospital mortality-morbidities, mid-term survival and revascularisation rate after CABG. Follow-up up to 7 years (median 3.2 years) was determined.

Results

Some 39 % (n = 510) of the cases involved novice (28 %-part, 11 %-whole procedure), 12 % (n = 157) competent trainees and 49 % (n = 638) consultant. Median EuroSCORE was higher in consultant group (p < 0.001). Without risk adjustment, composite outcome score and mid-term mortality were higher in consultant group (p = 0.03). With adjustment using EuroSCORE and propensity scores, EuroSCORE was significantly predictive of in-hospital mortality [odd ratio (OR) 1.38, 95 %CI 1.20–1.57, p < 0.001], composite outcome (OR 1.26, 95 %CI 1.15–1.37, p < 0.001) and mid-term mortality (HR 1.24, 95 %CI 1.18–1.31, p < 0.001) but not the operator categories. Further analysis of subcohort undergoing first-time, isolated CABG (n = 1070) showed that EuroSCORE remained predictive of adjusted in-hospital mortality (OR 1.39, 95 %CI 1.13–1.71, p = 0.002), composite outcome (OR 1.33, 95 %CI 1.19–1.49, p < 0.001) and mid-term mortality (HR 1.22, 95 %CI 1.10–1.35, p < 0.001). The operator categories were not associated with adjusted outcome measures including revascularisation rate after CABG.

Conclusion

Supervised training in adult cardiac surgery can be achieved safely at the early learning curve phase without compromising both early and mid-term clinical outcomes.     

Changes in the toilet training of children during the last 60 years: the cause of an increase in lower urinary tract dysfunction?

OBJECTIVE: To analyse the changes in toilet training of children in Belgium in the last three generations and to seek a possible cause for the apparent increase in lower urinary tract dysfunction over that period. PATIENTS AND METHODS: A questionnaire (25 questions) was developed and completed by 321 people who had toilet-trained 812 children. The population was divided into three groups according to the age of those who trained the children. RESULTS: There has been a major change in toilet training in the last 60 years; the age at which toilet training began has been significantly postponed. One reason for starting training, i.e. bladder control during the afternoon nap (which can probably be considered as an indication of sufficient bladder capacity) has become less important. Season (summer) has become a more important factor, as has starting school. Training by bladder drill, formerly widely used, was progressively abandoned and a more liberal attitude adopted by the youngest parents. CONCLUSION: There seems to be good concordance between the programmes currently proposed for treating bladder dysfunction in children and the traditional bladder-training methods used by parents 60 years ago. To start bladder training when the child stays dry during the afternoon nap and using bladder drill might help to avoid permanent bladder dysfunction. The lack of formal bladder training may be responsible for an increase in lower urinary tract dysfunction.     

Management of cancer of the ampulla of Vater: does local resection play a role?

BACKGROUND: The clinical outcome of patients with ampullary carcinoma is significantly more favorable than for patients with pancreatic head carcinoma. The Whipple procedure is the operation of choice for both diagnoses. Still local resection is recommended in selected cases. The aim of this study was to assess the outcome of local resection of cancer of the ampulla of Vater by comparison with pancreaticoduodenectomy. METHOD: 92 patients with cancer of the ampulla of Vater treated between 1975 and 1999 with local resection (n = 10), pancreatic resection (n = 49) or laparotomy and no resection (n = 33) were studied retrospectively. The main outcome measures were postoperative morbidity and mortality, surgical radicality and long-term survival. RESULTS: The postoperative complication rate was significantly lower after local resection (p = 0.036) whereas mortality did not differ between the 2 resection groups. UICC stages were less advanced in the local resection group (p < 0.04). Still, the frequency of positive resection margins and RO resections was the same in both groups, as was long-term survival. Local recurrence was diagnosed in 8/10 (80%) patients after local and in 11/49 (22%) patients after pancreatic resection (p = 0.001). CONCLUSION: Pancreaticoduodenectomy is the preferred operation for cancer of the ampulla of Vater in patients who are fit for the procedure. Local resection plays a limited role in carefully selected patients.     

Learning from the past: did experience with previous epidemics help mitigate the impact of COVID-19 among spine surgeons worldwide?

Purpose

Spine surgeons around the world have been universally impacted by COVID-19. The current study addressed whether prior experience with disease epidemics among the spine surgeon community had an impact on preparedness and response toward COVID-19.

Methods

A 73-item survey was distributed to spine surgeons worldwide via AO Spine. Questions focused on: demographics, COVID-19 preparedness, response, and impact. Respondents with and without prior epidemic experience (e.g., SARS, H1NI, MERS) were assessed on preparedness and response via univariate and multivariate modeling. Results of the survey were compared against the Global Health Security Index.

Results

Totally, 902 surgeons from 7 global regions completed the survey. 24.2% of respondents had prior experience with global health crises. Only 49.6% reported adequate access to personal protective equipment. There were no differences in preparedness reported by respondents with prior epidemic exposure. Government and hospital responses were fairly consistent around the world. Prior epidemic experience did not impact the presence of preparedness guidelines. There were subtle differences in sources of stress, coping strategies, performance of elective surgeries, and impact on income driven by prior epidemic exposure. 94.7% expressed a need for formal, international guidelines to help mitigate the impact of the current and future pandemics.

Conclusions

This is the first study to note that prior experience with infectious disease crises did not appear to help spine surgeons prepare for the current COVID-19 pandemic. Based on survey results, the GHSI was not an effective measure of COVID-19 preparedness. Formal international guidelines for crisis preparedness are needed to mitigate future pandemics.

     

The surgeon’s real dose exposure during balloon kyphoplasty procedure and evaluation of the cement delivery system: a prospective study

Purpose

Balloon kyphoplasty is currently widely used for the treatment of vertebral compression fractures (VCFs). Procedure safety is directly linked to precise radiological imaging generated by various X-ray systems (C-arm, O-arm^®, angiography table, etc.). This minimally invasive spinal surgery is, by definition, associated with significant radiation exposure for both patient and surgeon. Real dose exposure received by the surgeon is usually difficult to precisely record. In our center, all Balloon Kyphoplasty Procedures (BKP) are now performed using an O-arm^® image guidance system to control cement augmentation in VCF. Our preliminary experience described reduced dose exposure compared to C-arm guided procedures. We present here an additional way to considerably reduce the amount of radiation received by the surgeon during BKP using a new injection system.

Methods

We prospectively evaluated O-arm^® guided BKP in 20 consecutive patients alternatively allocated to either classic O-arm^® BKP with direct bone filler injection or BKP using a new Cement Delivery System (CDS). Eye, wrist, finger and leg measurements were taken bilaterally and compared between the two groups.

Results

The radiation dose received by the surgeon’s finger, wrist and leg was reduced by greater than 80 % when using the CDS. It allows the surgeon to work way below the most severe annual limit of dose exposure, which may not be the case when using a classical bone filler direct injection mechanism.

Conclusion

We believe that when using this new intraoperative injection system, the surgeon’s overall anatomic exposure is significantly reduced without compromising the critical procedure steps.     

A reflection on an adapted approach from face-to-face to telephone consultations in our Urology Outpatient Department during the COVID-19 pandemic – a pathway for change to future practice?

The sudden and unanticipated coronavirus disease 2019 (COVID-19) viral pandemic of 2020 and its profound impact on the NHS prompted an almost overnight change in the services we are able to offer our patients to fulfil clinical demands. From March 2020, we have changed outpatient appointments from face-to-face to telephone-led consultations. We have performed an early review of this service to ensure its sustainability during the unknown duration of this current crisis and to establish its potential utility when normal services resume in the future. Our present results show a patient satisfaction of 93%, with 83% happy to have telephone follow-up in the future, and a clinician satisfaction of 82% in the adequacy of the telephone consultation for making a clinical decision. Telephone clinics are a safe and efficient alternative to face-to-face outpatient consultations for many patients, particularly non-complex benign follow-ups.     

Spread of local anesthetic during an ultrasound‐guided interscalene block: does the injection site influence diffusion?

Background: During interscalene block (ISB) placement, ultrasound guidance (USG) enables the practitioner to measure the spread of local anesthetic around the nerve trunks or roots, and to adjust the needle position in order to optimize diffusion. Moreover, USG helps determine the best injection level, i.e. the point from which diffusion gives the most complete brachial plexus block. The aim of this study was to compare C5 and C6 level injections and to determine which level allows the best diffusion. Methods: Sixty randomized patients scheduled for shoulder surgery were divided into two groups. In group C5, injection was directed toward C5 while in group C6, the C6 nerve root was targeted. Block performance time was recorded. The onset of motor and sensory block of each nerve distribution was evaluated every 10 min over a 30‐min period. Results: The average time taken to perform a nerve block was 6.2+2.6 min in Group C6 and 6.0+2.1 min in Group C5 (NS). At 30 min, the number of patients with a satisfactory musculocutaneous and axillary nerve block was not notably greater in either group. By contrast, a significantly higher success rate was observed for other nerves in the C6 group as compared to the C5 group: ulnar nerve block: 93% vs. 19%, radial nerve block: 96% vs. 28%, median nerve block: 96%, vs. 69%. Conclusions: During USG ISB placement, injection below the C6 level provided the same efficiency in analgesia after shoulder surgery as an injection cranial to the C5 nerve root but a greater success rate of anesthesia in all distal nerve areas. This technique could be very interesting for trauma cases as an alternative to a supraclavicular block and offers a high success rate and is simple to perform, potentially promoting wide use and quicker learning for beginners.     

Recipient death during a live donor liver transplantation: who gets the "orphan" graft?

The limited availability of deceased organ donors, prolongation of waiting time, and increasing number of patients dying awaiting transplantation have contributed to the increased use of adult-to-adult living-donor liver transplant. In the event that the intended recipient dies after the donor graft has been procured but before it has been transplanted, what should be done with the graft? A structured, nine-item oral survey of 26 experts in liver transplantation was conducted in June and July 2003. Respondents were selected primarily because of their extensive experience with liver transplantation, especially adult-to-adult living-donor transplant. All respondents said the surgical team should try to use the available graft for another recipient. Twenty-one respondents believed consent from the donor or the donor's family was required for allocation, whereas 19% believed consent desirable but not required. Nine respondents recommended an allocation organization place the graft, whereas 17 respondents recommended placement within the donor hospital. Two of the respondents had previously encountered this situation, whereas four had experienced an intraoperative recipient death before procurement of a live donor graft. On the basis of the responses, we offer the following recommendations for handling orphan liver grafts: (1) obtain predonation informed consent from all donors that indicates what the donor would want to have done with the "orphan graft" in all cases of living-donor liver transplantation; (2) avoid the premature removal of the donor graft until the recipient hepatectomy and survival are likely; (3) if a live donor graft has been procured and cannot be transplanted into the intended recipient, and if informed consent has been obtained before the donor operation, the organ should be reallocated without delay to minimize cold ischemia time and maximize the utility of the graft.