Does segmentectomy really preserve the pulmonary function better than lobectomy for patients with early-stage lung cancer?

Purpose

Recently, segmentectomy has been considered as an alternative to lobectomy in early peripheral non-small lung cancer (NSCLC); however, controversy has remained regarding the long-term functional advantage after segmentectomy. The aim of this study was to analyze the postoperative lung function after segmentectomy and lobectomy for non-small cell lung cancer.

Methods

Patients with p-T1aN0M0 NSCLC who had undergone segmentectomy (n = 37) or lobectomy (n = 33) were retrospectively analyzed. The ratios of postoperative to preoperative forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1) were defined as the recovery rates. The radiological lung volume and weight were evaluated before and more than 6 months after surgery, and the postoperative values were compared with the predicted values that were calculated from the preoperative values, subtracting the resected lobes or segments.

Results

The clinical characteristics, including the preoperative lung function showed no significant differences between the groups. No statistical differences were recognized in the trend lines for recovery ratios of FVC and FEV1.0 (P = 0.96 and P = 0.33). The recovery ratios for radiologic lung volume and weight showed no significant differences (P = 0.46 and P = 0.22). The postoperative lung volume and weight were almost the same as the predicted values after segmentectomy, whereas those after lobectomy were significantly higher than the predicted values.

Conclusions

No functional advantage for segmentectomy was observed during long-term follow-up, possibly due to compensatory lung growth after lobectomy.

     

Video assisted thoracic surgery vs. thoracotomy for locally advanced lung squamous cell carcinoma after neoadjuvant chemotherapy

Background

Surgery is an important part of multidisciplinary treatment strategy for locally advanced lung squamous cell carcinoma (LSCC), but insufficient evidence supports the feasibility and safety of video assisted thoracic surgery (VATS) following neoadjuvant chemotherapy for locally advanced LSCC. This study aims to compare perioperative data and long-term survival of locally advanced LSCC patients between VATS and thoracotomy after neoadjuvant chemotherapy.

Methods

We retrospectively collected the clinical and pathological information of patients with locally advanced LSCC who underwent surgical resection after neoadjuvant chemotherapy from October 2013 to October 2017. All patients were divided into two groups (thoracotomy and VATS) and were compared the differences in perioperative, oncological and survival outcomes.

Results

A total of 81 patients were analyzed in this study (67 thoracotomy and 14 VATS). VATS provided less postoperative pain (P =?0.005) and produced less volume of chest drainage (P =?0.019) than thoracotomy, but the number of resected lymph nodes was less in VATS group (P =?0.011). However, there was no significant difference in the number of resected lymph node stations and the rate of nodal upstaging between two groups. The mean disease free survival (DFS) was 32.7?±?2.7?months for the thoracotomy group and 31.8?±?3.0?months for the VATS group (P?=?0.335); the corresponding overall survival (OS) was 41.7?±?2.2?months and 36.4?±?4.1?months (P?=?0.925).

Conclusion

In selected patients with locally advanced LSCC, VATS played a positive role in postoperative recovery and associated similar survival outcome compared with thoracotomy after neoadjuvant chemotherapy.

     

Intraoperative Nefopam Reduces Acute Postoperative Pain after Laparoscopic Gastrectomy: a Prospective,Randomized Study

Background

We assessed whether intraoperative nefopam would reduce opioid consumption and relieve postoperative pain in patients undergoing laparoscopic gastrectomy.

Methods

The 60 enrolled patients were randomly assigned to the control (n?=?32) or nefopam (n?=?28) group. All patients were blinded to their group assignment. We administered 100 ml of normal saline only (control group) or 20 mg of nefopam mixed in 100 ml normal saline (nefopam group) after anesthesia induction and at the end of surgery. The cumulative amount of fentanyl via intravenous patient-controlled analgesia (PCA), incidence of rescue analgesic medication, and numerical rating scale (NRS) for postoperative pain were evaluated along with the total remifentanil consumption.

Results

The mean infusion rate of remifentanil was significantly lower in the nefopam group (0.08?±?0.05 μg/kg/min) than in the control group (0.13?±?0.06 μg/kg/min) (P?<?0.001). Patients in the nefopam group required less fentanyl via intravenous PCA than those in the control group during the first 6 h after surgery (323.8?±?119.3 μg vs. 421.2?±?151.6 μg, P?=?0.009). Additionally, fewer patients in the nefopam group than in the control group received a rescue analgesic during the initial 6 h postoperatively (78.6 vs. 96.9%, P?=?0.028). The NRS measured while patients were in the post-anesthetic care unit was significantly lower in the nefopam group than in the control group (3.8?±?1.1 vs. 4.8?±?1.4, P?=?0.012). The subsequent NRS obtained after patients had been transferred to the general ward was comparable between the two groups during the following postoperative period.

Conclusions

Intraoperative nefopam decreased postoperative pain and opioid consumption in the acute postoperative period after laparoscopic gastrectomy. Hence, nefopam may be considered as a component of multimodal analgesia after laparoscopic gastrectomy.

     

Development and validation of a theoretical test of proficiency for video-assisted thoracoscopic surgery (VATS) lobectomy

Background

Testing stimulates learning, improves long-term retention, and promotes technical performance. No purpose-orientated test of competence in the theoretical aspects of VATS lobectomy has previously been presented. The purpose of this study was, therefore, to develop and gather validity evidence for a theoretical test on VATS lobectomy consisting of multiple-choice questions.

Methods

Four European VATS lobectomy experts were interviewed to explore their views on important theoretical VATS lobectomy knowledge (step 1). This information was used to construct the test items in compliance with existing guidelines for multiple-choice questions (step 2). The experts rated the relevance of the items to confirm content validity in a modified Delphi approach (step 3). Finally, the test was administered to physicians, who were categorised into different experience levels based on their experience in VATS procedures overall and in VATS lobectomies specifically. Their answers were used to achieve construct validity (step 4).

Results

Initially, 81 items were constructed and two Delphi iterations reduced the test to 50 items. Item analysis led to the exclusion of 19 items and the mean discrimination index of the 31 final items was 0.26. Cronbach’s alpha for internal consistency was 0.75. The mean item difficulty was calculated to 0.63. According to performed VATS procedures, significantly different test performances were detected when comparing the group performances (p = 0.002) and the experts performed significantly better than the novices (p < 0.001) and intermediates (p = 0.01). In the category of performed VATS lobectomies, significant group performances were also found. In this category, the experts were also significantly better than the novices (p < 0.001), the trainees (p = 0.002), and the intermediates (p = 0.01).

Conclusions

This study led to the development of a theoretical test on VATS lobectomy consisting of multiple-choice questions. Both content and construct validity evidence were established.

     

One-port video-assisted thoracic surgery versus three-port video-assisted thoracic surgery for primary spontaneous pneumothorax: a meta-analysis

Objective

To further understand the effects of video-assisted thoracic surgery (VATS) with one-port versus three-port VATS for primary spontaneous pneumothorax (PSP).

Methods

In this study, we searched information from the PubMed, Cochrane Library, Embase, ScienceDirect, Web of Science, China National Knowledge Infrastructure (CNKI), and Wanfang Data databases from inception to September 2015 to collect data of randomized controlled trials (RCTs) and cohort studies about one-port VATS versus three-port VATS for PSP. Two independent authors were committed to screen literature, extract data, and assess the risk of bias of related studies. Then, we used the RevMan 5.20 software for a meta-analysis of one-port VATS versus three-port VATS for PSP.

Results

Six cohort studies involving 310 patients were finally selected in this meta-analysis. The results of our study indicate that one-port VATS had a shorter hospital stay (SMD = ?0.39, 95 % CI ?0.69 to 0.09, P = 0.01), lower VAS score of 24-h post-operative pain (SMD = ?0.78, 95 % CI ?1.40 to ?0.52, P < 0.00001), shorter chest drainage time (SMD = ?0.68, 95 % CI ?1.15 to ?0.22, P = 0.004), and lower incidence of post-operative paraesthesia (OR = 0.13, 95 % CI 0.06 to 0.29, P < 0.00001) compared with three-port VATS. However, one-port VATS had a lower patient satisfaction score at 24 h (SMD = ?0.65, 95 % CI ?0.95 to ?0.35, P < 0.0001) and 48 h (SMD = ?0.46, 95 % CI ?0.71 to ?0.21, P = 0.0002). No differences in the recurrence of pneumothorax (OR = 0.58, 95 % CI 0.20 to 1.67, P = 0.32), the operation time (SMD = 1.01, 95 % CI ?4.63 to 2.60, P = 0.58), and the satisfaction score at 72 h (SMD = ?0.11, 95 % CI ?0.44 to 0.22, P < 0.00001) were noted between the groups.

Conclusion

Current evidence suggests that one-port VATS may have certain advantages over three-port VATS for PSP. More large-scale and high-quality studies are needed for authentication.

     

Glycemic Control after Sleeve Gastrectomy and Roux-En-Y Gastric Bypass in Obese Subjects with Type 2 Diabetes Mellitus

Background

Roux-en-Y gastric bypass (LRYGB) has weight-independent effects on glycemia in obese type 2 diabetic patients, whereas sleeve gastrectomy (LSG) is less well characterized. This study aims to compare early weight-independent and later weight-dependent glycemic effects of LRYGB and LSG.

Methods

Eighteen LRYGB and 15 LSG patients were included in the study. Glucose, insulin, GLP-1, and GIP levels were monitored during a modified 30 g oral glucose tolerance test before surgery and 2 days, 3 weeks, and 12 months after surgery. Patients self-monitored glucose levels 2 weeks before and after surgery.

Results

Postoperative fasting blood glucose decreased similarly in both groups (LRYGB vs. SG; baseline—8.1?±?0.6 vs. 8.2?±?0.4 mmol/l, 2 days—7.8?±?0.5 vs. 7.4?±?0.3 mmol/l, 3 weeks—6.6?±?0.4 vs. 6.6?±?0.3 mmol/l, respectively, P <?0.01 vs. baseline for both groups; 12 months—6.6?±?0.4 vs. 5.9?±?0.4, respectively, P <?0.05 for LRYGB and P <?0.001 for LSG vs. baseline, P =?ns between the groups at all times). LSG, but not LRYGB, showed increased peak insulin levels 2 days postoperatively (mean?±?SEM; LSG +?58?±?14%, P <?0.01; LRYGB ??8?±?17%, P =?ns). GLP-1 levels increased similarly at 2 days, but were higher in LRYGB at 3 weeks (AUC; 7525?±?1258 vs. 4779?±?712 pmol?×?min, respectively, P <?0.05). GIP levels did not differ. Body mass index (BMI) decreased more after LRYGB than LSG (??10.1?±?0.9 vs. ??7.9?±?0.5 kg/m², respectively, P <?0.05).

Conclusion

LRYGB and LSG show very similar effects on glycemic control, despite lower GLP-1 levels and inferior BMI decrease after LSG.

     

FGF 19 and Bile Acids Increase Following Roux-en-Y Gastric Bypass but Not After Medical Management in Patients with Type 2 Diabetes

Background

This study aims to quantify changes in fibroblast growth factor 19 (FGF19) and bile acids (BAs) in patients with uncontrolled type 2 diabetes randomized to Roux-en-Y gastric bypass (RYGB) vs intensive medical management (IMM) and matched for similar reduction in HbA1c after 1 year of treatment.

Methods

Blood samples were drawn from patients who underwent a test meal challenge before and 1 year after IMM (n?=?15) or RYGB (n?=?15).

Results

Mean HbA1c decreased from 9.7 to 6.4 % after RYGB and from 9.1 to 6.1 % in the IMM group. At 12 months, the number of diabetes medications used per subject in the RYGB group (2.5?±?0.5) was less than in the IMM group (4.6?±?0.3). After RYGB, FGF19 increased in the fasted (93?±?15 to 152?±?19 pg/ml; P?=?0.008) and postprandial states (area under the curve (AUC), 10.8?±?1.9 to 23.4?±?4.1 pg?×?h/ml?×?10³; P?=?0.006) but remained unchanged following IMM. BAs increased after RYGB (AUC ×10³, 6.63?±?1.3 to 15.16?±?2.56 μM?×?h; P?=?0.003) and decreased after IMM (AUC ×10³, 8.22?±?1.24 to 5.70?±?0.70; P?=?0.01). No changes were observed in the ratio of 12α-hydroxylated/non-12α-hyroxylated BAs. Following RYGB, FGF19 AUC correlated with BAs (r?=?0.54, P?=?0.04) and trended negatively with HbA1c (r?=??0.44; P?=?0.09); these associations were not observed after IMM.

Conclusions

BA and FGF19 levels increased after RYGB but not after IMM in subjects who achieved similar improvement in glycemic control. Further studies are necessary to determine whether these hormonal changes facilitate improved glucose homeostasis.

     

Neutrophil activation,protein oxidation and ceruloplasmin levels in children with Henoch-Schönlein purpura

The aim of this study was to investigate the role of neutrophil activation, protein oxidation and ceruloplasmin (CLP) in the pathogenesis of Henoch-Schönlein purpura (HSP), which has not been investigated previously. Serum activities of myeloperoxidase (MPO) and arylesterase (ARYL) and levels of free thiol groups, CLP and total oxidant status (TOS) were measured in 29 children with HSP at the onset of the disease and during remission in comparison with 30 healthy subjects. Patients at active stage had significantly higher MPO activity (391?±?277 vs. 155?±?154 U/l, P? P?2O₂/l, P?3?±?39?×?10³ vs. 187?×?10³?±?46?×?10³ U/l, P? P?r?=?0.437, P?=?0.018) and TOS and CLP (r?=?0.409, P?=?0.028) at disease onset, whereas a negative correlation was found between MPO and thiol (r?=??0.597, P?=?0.001) during remission. In conclusion, protein oxidation and neutrophil activation may play important roles in the pathogenesis of HSP. Further research is required to understand the potential linkage between oxidant stress and complications and to develop therapeutic strategies in HSP.     

Comparative study of the treatment of 20–30 mm renal stones with miniaturized percutaneous nephrolithotomy and flexible ureterorenoscopy in obese patients

Purpose

To evaluate and compare flexible ureteroscopy (f-URS) and mini-percutaneous nephrolithotomy (mPNL) for 20–30 mm renal stones in obese patients regarding efficacy and safety.

Methods

Between May 2011 and June 2017, 254 obese patients who had 20–30 mm kidney stone were consecutively included in the study; 106 patients underwent mPNL and 148 underwent f-URS by the same surgeon. The following parameters were retrospectively assessed: patient and stone characteristics, surgical details, perioperative outcomes, and stone-free rates (SFR).

Results

F-URS group was similar to mPNL group in terms of the mean duration of surgery (92.8?±?26.1 vs 87.4?±?31.5 min, P?=?0.137) and the final SFR (89.1 vs 92.5%, P?=?0.381). The f-URS group had significantly shorter postoperative stay (1.0?±?0.8 vs 4.3?±?1.7 days, P?<?0.001) and lower postoperative complications (11.5 vs 26.4%, P?=?0.002). However, the f-URS group had a lower SFR after first session (67.2 vs 87.4%, P?<?0.001) and needed more number of procedures (1.5?±?0.4 vs 1.3?±?0.4, P?<?0.001) than the mPNL group.

Conclusions

MPNL has a higher efficacy (higher SFR after first session and lower number of procedures); however, f-URS offers advantages regarding safety (lower complication rate). Therefore, both options can be offered to obese patients with renal stones from 20 to 30 mm in size. Nevertheless, these results must be confirmed by further prospective randomized trials.

     

Intragastric Balloon in Association with Lifestyle and/or Pharmacotherapy in the Long-Term Management of Obesity

Background

Intragastric balloon (BioEnterics Intragastric Balloon, BIB®) or pharmacotherapy are possible options for the treatment of obese patients when traditional approaches have failed. The aim of our study was to compare in obese patients the effect on weight loss and metabolic changes of lifestyle modifications associated with either BIB or pharmacotherapy or the two treatments in sequence as a maintenance strategy for weight loss.

Methods

Fifty obese patients were recruited and randomly assigned to lifestyle modifications combined with either BIB for 6 months (n?=?30) or sibutramine (pharmacotherapy group) for 1 year (n?=?20). After BIB removal, patients were randomly assigned to either correct lifestyle (BIB/lifestyle) or lifestyle plus pharmacotherapy (BIB/pharmacotherapy).

Results

At 6 months, patients treated with BIB lost significantly (P?P?P?

Conclusions

BIB represents an efficacious long-term obesity treatment when supplemental strategies, as lifestyle modifications or pharmacotherapy, are established for weight maintenance after its removal.

     

Elevated visceral obesity quantified by CT is associated with adverse postoperative outcome of laparoscopic radical nephrectomy for renal clear cell carcinoma patients

Purpose

To examine the association between CT measures of visceral obesity and short-term postoperative outcomes in renal clear cell carcinoma (RCCC) patients.

Methods

In this retrospective study, 76 patients treated with unilateral laparoscopic radical nephrectomy for stage I–III renal cancer were classified as obese or non-obese by preoperative CT-based measures of adiposity [obese: visceral fat area (VFA)?>?100 cm², BMI?≥?28 kg/m²]. Clinical variables, Fuhrman grade, operation time, estimated blood loss (EBL), postoperative complications, postoperative stay, drainage time and hospitalization expenses were compared between the two groups.

Results

Viscerally obese patients significantly had higher Fuhrman grade than the non-obese (p?=?0.018). The operation time of obese patients by VFA or BMI was more than the non-obese (171.6?±?68.9 vs. 140.8?±?35.5 min, p?=?0.012 and 197.2?±?67.2 vs. 153.2?±?57.7 min, p?=?0.013, respectively). And obese patients by VFA or BMI tended to have more EBL than non-obese (132.0?±?120.7 vs. 83.8?±?53.4 ml, p?=?0.018 and 215.3?±?165.0 vs. 92.5?±?68.8 ml, p?=?0.013, respectively). Viscerally obese patients by VFA (not BMI) were more likely to develop postoperative complications as compared to patients classified as non-obese: VFA (26.9 vs. 4.2%, p?=?0.045) and BMI (33.3 vs. 16.4%, p?=0.265). Furthermore, obese patients by VFA (not BMI) were more likely to have longer postoperative stay: VFA (8.7?±?2.5 vs. 7.5?±?1.4 dollars, p?=?0.013) and BMI (9.1?±?2.9 vs. 8.1?±?2.1 dollars, p?=?0.209). Obese patients expensed more than non-obese: VFA (7570.9?±?2674.3 vs. 6368.8?±?1289.8 dollars, p?=?0.040) and BMI (8390.8?±?2929.7 vs. 6896.3?±?2159.1 dollars, p?=?0.029).

Conclusions

Elevated visceral obesity by VFA is associated with increased surgical complexity, postoperative morbidity, postoperative stay and hospitalization expenses for RCCC patients and may be superior to BMI for renal cancer outcome assessment. VFA may be a useful index for the evaluation and calculation of RCCC aggressiveness.

     

Comparison of Vela and holmium laser enucleation of the prostate: a retrospective clinical trial with a 12-month follow-up

Purpose

This study aimed to estimate the validity and applicability of Vela laser enucleation of the prostate (VoLEP) in the management of benign prostatic hyperplasia (BPH).

Methods

A retrospective chart review of 112 patients with BPH who underwent VoLEP (n?=?60) or holmium laser enucleation of the prostate (HoLEP) (n?=?56) was conducted at our institution from January 2015 to June 2015. The general and perioperative characteristics of the patients were collected. The 12-month follow-up data, including the lower urinary tract symptom (LUTS) indexes (International Prostate Symptom Score [I-PSS], quality-of-life [QoL] score and maximum flow rate [Qmax]), as well as rates of perioperative and late complications, were analyzed.

Results

No significant differences were observed in pre- and perioperative parameters, including operation time (58.05?±?10.14 vs. 60.14?±?12.30 min, P?=?0.44), serum sodium decrease (3.49?±?0.83 vs. 3.48?±?0.84 mmol/L, P?=?0.97), hemoglobin decrease (1.28?±?0.38 vs. 1.24?±?0.77 g/dL, P?=?0.71), catheterization time (3.63?±?1.10 vs. 3.89?±?1.11 days, P?=?0.21) and hospital stay (4.57?±?1.25 vs. 4.68?±?1.18 days, P?=?0.63) between the two groups of patients. Compared with the HoLEP group, the noise during operation was lower in VoLEP group (47.22?±?10.31 vs. 59.45?±?9.65 db, P?<?0.05). During 1, 6 and 12 months of follow-up visits, the LUTS indexes (I-PSS, QoL score and Qmax) were remarkably improved in both groups when comparing with the baseline values. Furthermore, LUTS indexes were comparable in both groups (P?>?0.05).

Conclusion

Similarly as the holmium laser, the Vela laser is a potent, safe, efficient durable and surgical treatment option for minimally invasive surgery in patients with BPH-induced LUTS.

     

Intermittent Pringle Versus Continuous Half-Pringle Maneuver for Laparoscopic Liver Resections of Tumors in Segment 7

Segment 7 is considered an unfavorable portion for laparoscopic hepatectomy because of technical difficulties in exposure and controlling bleeding. We compared intermittent Pringle with continuous half-Pringle maneuver in laparoscopic liver resections of tumors in segment 7. A retrospective analysis was conducted in a total of 36 consecutive patients with tumors in segment 7 undergoing laparoscopic liver resections between July 2011 and February 2016 (16 in the Pringle group versus 20 in the half-Pringle group). The two groups were well matched in baseline characteristics. The operative time (274.5?±?34.3 versus 237.6?±?41.8 min), overall declamping time (28.4?±?8.6 versus 2.3?±?2.5 min), and ischemic duration (69.7?±?16.5 versus 52.7?±?13.2 min) were significantly longer in the Pringle group (P?<?0.05). The amount of intraoperative blood loss (612.5?±?222.3 versus 417.4?±?163.8 mL) and transfusion (335.2?±?58.7 versus 224.8?±?76.2 mL) was significantly greater in the Pringle group (P?<?0.05). The Pringle group was associated with significantly lower postoperative albumin and higher C-reactive protein levels on postoperative days 1, 3, and 7 (P?<?0.05). Laparoscopic hepatectomy for tumors in segment 7 can be performed safely and effectively with successful exposure of surgical field and proper hepatic blood flow occlusion. Continuous half-Pringle maneuver offers the advantages of less operative time and blood loss, less injury, and better recovery.     

A Comparative Study of Video-Assisted Thoracic Surgery with Thoracotomy for Middle Lobe Syndrome

Objectives

The aim of this study is to evaluate the feasibility and safety of video-assisted thoracic surgery (VATS) for the treatment of middle lobe syndrome (MLS) through comparison with thoracotomy during the same period.

Methods

We retrospectively reviewed all consecutive patients with MLS who underwent lobectomy or lingular segmentectomy between December 2005 and November 2015 in a single institute. Thirty patients were enrolled and divided into two groups: VATS group (n = 19) and thoracotomy group (n = 11). Data regarding the patients’ demographics, medical history were collected and statistically compared.

Results

All patients received successful middle lobe resection or lingular segmentectomy. In terms of operation time, blood transfusion, chest drainage amount, duration of chest drainage and postoperative complications, no significant differences were found between the two groups (p > 0.05). The mean intraoperative blood loss of VATS group was less than thoracotomy group (79.0 ± 63.9 vs. 165 ± 94.9 ml, p = 0.04). In VATS group, the mean length of postoperative hospital stay was 6.0 ± 2.4 days, shorter than that in group thoracotomy (9.0 ± 3.5 days, p = 0.01).

Conclusions

VATS was a feasible and safe method for the surgical treatment of MLS in selected patients when no severe calcified lymph nodes surrounding hilus pulmonis was observed by preoperative chest CT scan.

     

Risk factors for predicting increased surgical drain output in patients after anterior cervical corpectomy and fusion

Background

Although measures to reduce and treat the postoperative surgical drain output are discussed, along with the increased interest in causative factors related to the prevention and treatment reported by many studies, these are still controversial.

Methods

A retrospective study was conducted on a consecutive series of 217 patients who had underwent ACCF between January 2016 and March 2017. Patients were categorized based on normal or increased total drain output. These two groups were compared for demographic distribution and clinical data to investigate the predictive factors of increased drain output by multivariate analysis.

Results

The overall incidence rate of increased drain output after ACCF was 16.6%. There are no significant differences in sex, BMI, history of taking aspirin, and ASA classification between the two groups (P?>?0.05). Of the patients with increased drain output, a significantly higher proportion of patients have OPLL in the surgical level, 18 (50.0%) versus 33 (18.2%) (P?=?0.000). The mean age was 60.67?±?8.18 years versus 54.41?±?10.05 years (P?=?0.001). Number of discs involved was 2.42?±?0.50 versus 2.02?±?0.65 (P?=?0.001). Operation time was 112.22?±?16.49 min versus 105.21?±?17.89 min (P?=?0.031). Intraoperative blood loss was 109.86?±?62.02 mL versus 87.83?±?56.40 mL (P?=?0.036). Logistic regression analysis showed that age (OR, 1.075; p?=?0.003), history of smoking (OR, 2.792; p?=?0.021), OPLL in surgical level (OR, 2.107; p?=?0.001), and number of discs involved (OR, 2.764; p?=?0.003) maintained its significance in predicting likelihood of increased surgical drain output.

Conclusions

The occurrence of increased drain output after ACCF is most likely multifactorial and is related to age, history of smoking, OPLL in surgical level, and number of discs involved.

     

Cost-Effectiveness in Hepatic Lobectomy: the Effect of Case Volume on Mortality,Readmission, and Cost of Care

Objective(s)

Higher-volume centers demonstrate better perioperative outcomes for complex surgical interventions, though resource utilization implications of this hospital-level variation are unclear. We hypothesized that for hepatic lobectomy, higher operative volume correlates with better outcomes and lower costs.

Methods

From 2009 to 2011, 4163 patients undergoing hepatic lobectomy were identified from the University HealthSystems Consortium database. Univariate, multivariate logistic regression, and decision analytic models were constructed to identify differences in hospital utilization and cost. Cost included both index and readmission hospitalizations, when applicable.

Results

The annual number of hepatic lobectomies performed by the institutions within the study ranged from 1 to 86. The median age of the 4163 patients was 58 years with a roughly equal gender split (M/F 49 %:51 %) and a racial breakdown which reflected that of the general US population. For all patients, the overall perioperative mortality rate was 2.3 % and the 30-day readmission rate was 13.4 %. Hospitals performing >30 hepatic lobectomies per year had significantly lower mortality and readmission rates than those hospitals performing ≤15 lobectomies annually (both p?<?0.05). On multivariate analysis, higher severity of illness (odd ratio (OR) 2.13, 95 % confidence interval (CI) [1.48–3.07], p?<?0.001), discharge to rehab (OR 1.84, [1.28–2.64], p?<?0.001), home with home health care (OR 1.38, [1.08–1.76], p?=?0.01), and surgery at a low-volume hospital (OR 1.49, [1.18–1.88], p?<?0.001) were significant predictors of readmission. Conversely, surgical intervention at high-volume centers was associated with decreased risk of readmission (OR 0.67, [0.53–0.85], p?<?0.001). When both index and readmission costs were considered, per-patient cost at low-volume centers was 21.9 % higher than at high-volume centers ($19,669 vs. $16,137). Sensitivity analyses adjusting for perioperative mortality and readmission at all centers did not significantly change the analysis.

Conclusions

These data, for the first time, demonstrate that hospital volume in hepatic lobectomy is an important, modifiable risk factor for readmission and cost. To optimize resource utilization, patients undergoing complex hepatic surgery should be directed to higher-volume surgical institutions.

     

Dyslipidemia,carotid intima-media thickness and endothelial dysfunction in children with chronic kidney disease

Background

Chronic kidney disease (CKD) predisposes to accelerated atherosclerosis that is measured by carotid artery intima-media thickness (cIMT) and brachial artery flow-mediated dilation (FMD). Information on the association of these parameters with dyslipidemia in pre-dialysis pediatric CKD is limited.

Methods

Eighty patients aged 9.9?±?3.2 years, with estimated glomerular filtration rate of 38.8?±?10.8 ml/1.73 m²/min, and 42 pediatric controls underwent cross-sectional analysis of lipid profile, cIMT, and brachial artery FMD. Significant differences in these parameters between patients and controls were analyzed using Student’s t test. Predictors of cIMT and dyslipidemia were assessed using linear and logistic regression respectively.

Results

Patients had elevated blood levels of triglyceride and of total and LDL cholesterol than controls (P?≤?0.001); 73.8 % were dyslipidemic. Mean cIMT was higher (0.421?±?0.054 mm vs 0.388?±?0.036 mm, P?=?0.001) and brachial artery FMD was reduced (10.6?±?4.9 % vs 18.9?±?4.1 %, P?<?0.0001) in patients compared with controls. On multivariate analysis, hypertension (OR 3.68, P?=?0.044) and male gender (OR 10.21, P?=?0.004) were associated with dyslipidemia; cIMT was significantly associated with LDL cholesterol (β?=?28.36, P?=?0.033).

Conclusion

Dyslipidemia was prevalent and cIMT significantly elevated in pre-dialysis pediatric CKD, indicating increased cardiovascular risk. Elevated LDL cholesterol predicted increased cIMT, strengthening the association between dyslipidemia and atherosclerosis in early CKD.

     

Feasibility of single-incision thoracoscopic surgery using a modified chest wall pulley for primary spontaneous pneumothorax: a propensity score matching analysis

Purpose

Recently, single-incision thoracoscopic surgery (SITS) has been recognized as a favorable treatment choice for primary spontaneous pneumothorax (PSP) compared with conventional three-port video-assisted thoracoscopic surgery (VATS). However, conventional SITS bullectomy often results in collisions with surgical devices. Therefore, we devised a method of SITS using a chest wall pulley for lung excision (PulLE) and modified PulLE (mPulLE) system, which substitutes threads to eliminate such collisions. We compared the mPulLE system with conventional procedures using propensity score matching (PSM) to adjust for patient backgrounds.

Methods

Using PSM, we evaluated the surgical results of 210 PSP patients who underwent VATS, including mPulLE (n?=?23) and three-port VATS (n?=?102), at our institution between January 2010 and August 2016.

Results

We selected 17 mPulLE cases and 17 three-port VATS. There were no marked differences between the groups in the patient backgrounds or surgical results. However, there was a significant difference between the mPulLE cases and the three-port VATS cases in the operative time (71.7?±?15.7 vs. 85.9?±?25.5 min, respectively, P?=?0.0388) and the number of autosutures used (3.6?±?1.2 vs. 4.5?±?1.2, respectively, P?=?0.0178).

Conclusion

The surgical results of mPulLE in patients with PSP with multiple lesions were equivalent to those achieved with three-port VATS under the same conditions.

     

Recovering sexual satisfaction after prolapse surgery: a secondary analysis of surgical recovery

Introduction and hypothesis

We compared pre- and postoperative sexual function scores in sexually active women undergoing pelvic organ prolapse (POP) surgery.

Methods

Planned secondary analysis of women enrolled in the Restricted Convalescence: Outcomes Following Urogynecologic Procedures study, a randomized trial of postoperative activity after POP surgery. All participants could return to sexual activity at 6 weeks. Participants completed the Pelvic Floor Distress Inventory (PFDI), the Patient-Reported Outcomes Measurement Information System (PROMIS) profile, and the Golombok Rust Inventory of Sexual Satisfaction (GRISS) questionnaires at baseline and 3 months. GRISS is a validated 28-item survey for heterosexual couples that contains seven subscales to assess sexual function. Higher scores represent worse sexual function.

Results

Thirty-seven sexually active women were assessed. Mean age?±? standard deviation (SD) was 56?±?11, most of whom (92%) were Caucasian; 78% had undergone minimally invasive sacrocolpopexy, and the remainder had native tissue vaginal repairs. GRISS scores improved 3 months after surgery [4.5?±?2.6 to 3.6?±?2.2, p <?0.001; mean decrease of 0.9, 95% confidence interval (CI) 0.36–1.36]. PFDI scores improved from 122?±?53 at baseline to 28?±?31 at 3 months (p <?0.001). Higher GRISS scores were correlated with higher PFDI scores (Spearman’s rho?=?0.35, p =?0.03) at baseline and 3 months (Spearman’s rho?=?0.31, p?=?0.03). Several GRISS subscales improved after surgery: partner avoidance (p =?0.01), vaginismus (p =?0.02), noncommunication (p?=?0.01), dissatisfaction (p =?0.03), and anorgasmia (p =?0.001). However, sexual infrequency (p =?0.08) and nonsensuality (p =?0.4) did not change. Fifty-one percent had sexual dysfunction before surgery, which decreased to 32% after surgery (p =?0.04).

Conclusion

Sexual function and satisfaction are significantly improved 3 months following POP surgery. Improved sexual function is correlated with improved pelvic floor symptoms.

     

Primary Closure Following Laparoscopic Common Bile Duct Reexploration for the Patients Who Underwent Prior Biliary Operation

To assess feasibility of primary closure following laparoscopic common bile duct reexploration for the patients who underwent prior biliary operation, we retrospectively studied 50 patients with recurrent or residual common bile duct (CBD) stones who underwent laparoscopic biliary reoperation between June 2008 and June 2013. Endoscopic sphincterotomy (EST) was treated for all these patients and validated failed. They were divided into two groups. Primary closure following laparoscopic common bile duct exploration (LCBDE) was performed in 25 cases (group A); LCBDE plus T-tube drainage was performed in others (group B). The items of operation were compared. The duration of the operation in group A was shorter than that in group B (141?±?85 vs 158?±?71 min, p?<?0.05), as was postoperative hospital stay (16?±?2.3 vs 23?±?2.3 h, p?<?0.05) and the times of postoperative gastrointestinal function recovery (16?±?2.3 vs 23?±?2.3 h, p?<?0.05). Just one duodenum was damaged in group B. Postoperative clinically significant bile leakage occurred in two patients in group A and one case in group B. The median follow-up was 18 months. No postoperative pancreatitis, postoperative bleeding, bile peritonitis after T-tube removal, stricture of bile duct, and death occurred in the two groups. Just two cases in group B were verified residual stones after 1 month. Primary closure following laparoscopic common bile duct reexploration for the patients who underwent prior biliary operation appears to be a minimally invasive, safe, feasible, and effective procedure when done by expert laparoscopic surgeons.