Routine Anterior Approach During Right Hepatectomy: Results of a Prospective Randomised Controlled Trial

Trial Design

A prospective randomised controlled trial was designed to evaluate the advantages of routine application of the anterior approach during right hepatectomy.

Methods

The study was conducted between March 2005 and April 2009 in a tertiary hepatobiliary?Cpancreatic centre. Patients scheduled for right hepatectomy for primary or metastatic tumours, without infiltration of segment 1, inferior vena cava or main bile duct, were randomly assigned to right hepatectomy using either an anterior or a classic approach. The primary study endpoint was overall blood loss.

Results

Sixty-six patients were randomly allocated to undergo right hepatectomy with an anterior (AA group n?=?33) or a classic approach (CA group n?=?33). Sixty-five patients were included in the analysis (33 in AA group and 32 in CA group). There was no significant difference in patient age, diagnosis, preoperative hepatic biochemistry and tumour size between the two groups. Overall blood loss (437?ml?±?664 in AA group vs.500?ml?±?532.3 in CA group; p?=?0.960) and bleeding during transection (p?=?0.973) were similar between two groups. Perioperative blood transfusion rates were 18?% in the AA group and 9.3?% in the CA group (p?=?0.253). Time of parenchymal transsection was significantly longer in AA group (75.1?±?26.6?min vs. 56.7?±?17.5?min, p?=?0.01). There was no difference between both groups for postoperative prothrombin time, serum transaminase and total bilirubin levels. One patient died in each group (p?=?0.746). The two groups had similar morbidity rates.

Conclusion

Routine application of the anterior approach during right hepatectomy does not decrease intraoperative blood loss and morbidity rate.     

Comparison of Laparoscopy-Assisted and Open Donor Right Hepatectomy: a Prospective Case-Matched Study from China

Background

Laparoscopy-assisted hepatectomy is a new minimally invasive approach for graft harvesting in living donors. Only a few liver transplant centers have introduced this surgical procedure.

Methods

A prospective case-matched study was conducted on 25 consecutive donors who underwent laparoscopy-assisted donor right hepatectomy (LADRH) between July 2011 and March 2013 at our transplant center. These donors were matched 1:1 according to age, gender, and body mass index with 25 donors who underwent open donor right hepatectomy (ODRH).

Results

LADRH was successfully performed in all 25 of the donors. Donor complications, estimated blood loss, and operative time were similar between the groups. Hospital stay and periods of analgesic use were significantly shorter in the LADRH group [7.0?±?1.4 (LADRH) vs 8.7?±?2.4 (ODRH), p?=?0.003, and 2.4?±?1.0 (LADRH) vs 3.2?±?1.0 (ODRH), p?=?0.011, respectively). The total in-hospital cost is higher with LADRH, primarily due to the additional material costs for LADRH. Finally, there were no differences in graft size, graft survival, or recipient complications between the two groups.

Conclusion

The results of this study show that LADRH is a feasible and safe procedure compared with ODRH. Although higher material costs for laparoscopic assisted procedures are inevitable, LADRH may have an advantage over ODRH by causing less pain and facilitating earlier recovery. Efforts can be made to improve the technical success of LADRH for some overweight donors.     

Impact of intraoperative blood loss on the short-term outcomes of laparoscopic liver resection

Background

Intraoperative blood loss is one of the predictors of outcome of open hepatectomy. But the impact of blood loss in laparoscopic hepatectomy (LH) on postoperative outcomes is poorly understood. The aim of this study is to analyze the association between blood loss and postoperative outcomes after LH.

Methods

A retrospective analysis of prospectively maintained database of patients undergoing LH from 1995 to 2016 was performed. The data were divided into two groups based on the extent of blood loss: Group 1 (<250 ml) and Group 2 (≥250 ml). The basic characteristics and postoperative outcomes were compared between these groups.

Results

A total of 504 patients underwent 611 LH (Group 1: 414 and Group 2: 197). The mean age was 62.4 years. The most common indication was liver secondaries (71.7%). Major hepatectomy was performed in 37% cases. Mean operative time was 225?±?110.5 min and estimated blood loss was 239?±?399.4 ml (range 0–4500 ml). Group 2 had significantly higher number of patients with malignant lesions undergoing major hepatectomy, anatomical resection with higher requirement for blood transfusion, and longer hospital stay. The incidence of conversion rate, overall complications including liver failure, renal failure, and postoperative mortality, was significantly higher in Group 2. However, the bile leak rate was similar in the two groups.

Conclusion

Intraoperative blood loss is most frequent in patients undergoing major LH. Blood loss ≥250 ml during LH may adversely affect the postoperative outcomes.

     

Usefulness of Pyloric Reconstruction Without Compromising Curative Resection in Gastric Cancer Treatment

Introduction

We herein report the short-term results of the newly developed modified technique of Billroth I (modified B-I; pylorus reconstruction) that prevents duodenogastric reflux (DGR) and remnant gastritis after distal gastrectomy.

Patients and Methods

Distal gastrectomy with this technique was performed in 20 patients (age, 41 to 86?years [mean, 68.5?±?11.8?years], male/female?=?12:8) with gastric cancer from June 2006 through December 2009. These patients were compared with another 20 patients who underwent conventional B-I after distal gastrectomy (age, 41 to 85?years [mean, 69.3?±?8.69?years], male/female?=?11:9). The side effects of gastric surgery evaluated in this study were the degree of remnant gastritis, the presence of dumping syndrome, and the degree of weight loss.

Results

By gastrografin contrast imaging on the fifth day after pylorus reconstruction, the remnant stomach was not dilated and gastrografin flowed physiologically to the duodenum without backward reflux into the remnant stomach. By gastroscopy at 6?months after the operation, DGR and the degree of remnant gastritis after pylorus reconstruction was lower than those of conventional B-I (P?=?0.00068). The bile acid concentration of remnant gastric juice of pylorus reconstruction was lower than that of conventional B-I (55.5?±?93.5 vs. 1,369.5?±?2,502.1???mol/L, P?=?0.0415). Weight loss at 1?year after distal gastrectomy was less in pylorus reconstruction compared with conventional B-I (6.2?±?5.2% vs. 9.8?±?8.7%, P?=?0.0725).

Conclusion

Pylorus reconstruction is a simple and safe anastomotic technique that reduces the side effects of B-I reconstruction.     

A safety,length of stay,and cost analysis of minimally invasive microsurgery for anterior circulation aneurysms

Objectives

The aim of our study was to evaluate minimally invasive techniques for the treatment of anterior circulation aneurysms versus standard surgery, and to calculate the impact of these techniques on health resources, length of stay, and treatment costs.

Methods

A consecutive series of 24 patients with ruptured and 30 with unruptured anterior circulation aneurysms treated with minimally invasive microsurgery (MIM) by the same surgeon was compared with a matched series of standard microsurgeries (SM) conducted for 23 ruptured and 22 unruptured aneurysms. Complication rates, aneurysm obliteration, modified Rankin Scale (mRS) outcomes, length of stay, and treatment costs were assessed.

Results

Surgical complications, aneurysm obliteration rates and mRS outcomes were comparable between MIM and SM groups in ruptured and unruptured aneurysm cohorts. MIM resulted in shorter operative times both in unruptured (102.7?±?4.35 vs 194.7?±?10.26 min, p?<?0.0001) and ruptured aneurysms (124.3?±?827 vs 209?±?13.84 min, p?<?0.0001). Length of stay was reduced in patients with MIM for unruptured aneurysms (1.55?±?24 vs 4.28?±?0.71 days, p?<?0.000,1) but not in those with ruptured aneurysms. MIM reduced treatment costs of unruptured aneurysm patients, mainly through reduced utilization of inpatient resources (non-acute bed costs in CAD: 371.2?±?80.99 vs 1440?±?224.1, p?<?0.0001), whereas costs were comparable in patients with ruptured aneurysms.

Conclusion

Minimally invasive surgery is a safe and effective approach for the treatment of ruptured and unruptured aneurysms of the anterior circulation. In patients with unruptured aneurysms, reduced invasiveness and shorter operative times decreased length of stay, which reflects improved patient postoperative recovery. Overall, this translated into bed resource economy and cost reduction.     

Function and volume recovery after partial hepatectomy: influence of preoperative liver function, residual liver volume, and obesity

Background

The regenerative capacity of the liver is an essential pre-condition for the successful application of partial hepatectomy. However, the actual kinetics of functional recovery remains unspecified and no adequate tool for its clinical monitoring has yet been available.

Methods

Eighty-five patients receiving major hepatectomy were investigated from the preoperative evaluation until 12?weeks after surgery. Liver function was determined by the LiMAx test for the enzymatic capacity of cytochrome P450 1A2. Liver volume was determined by volumetric analysis of repeated computer tomography scans. Functional and volume recovery were compared during follow-up.

Results

Major hepatectomy decreased liver function capacity to 35.7?±?13.8?% of preoperative function. It was shown that functional recovery already reaches 77.2?±?33.5?% of preoperative values within 10?days. The actual kinetics were dependent from the type and extent of hepatectomy. Complete functional restoration was achieved within 12?weeks, while liver volume still remained at 73.2?±?14.8?% of preoperative. A constant but interindividually variable correlation between function and volume was observed at all points in time.

Conclusion

Partial hepatectomy leads to fast and complete functional recovery, while volume recovery is delayed and remains often incomplete. The functional recovery is mainly influenced by the preoperative liver function, the residual liver volume, and by obesity.     

Cinacalcet effects on the perioperative course of patients with secondary hyperparathyroidism

Purpose

Since its registration in 2004, the calcimimetic agent cinacalcet has been established as an alternative treatment for secondary hyperparathyroidism (SHPT). Working by allosteric activation of the calcium-sensing receptor, cinacalcet can lower parathyroid hormone (PTH) and calcium (Ca) in patients with SHPT. The influence of calcimimetics on the perioperative course has been unclear so far.

Methods

We retrospectively analyzed the data of patients with primary operation for SHPT between 2004 and 2011, comparing the perioperative course of patients with and without preoperative cinacalcet treatment.

Results

Fifty-six patients had cinacalcet therapy, and 54 patients had no calcimimetic medication prior to surgery. Gender, age, hemodialysis, and medical treatment were similar in both groups. Also, PTH levels were similar preoperatively and postoperatively (preoperative, 1,249?±?676 vs. 1,196?±?601 pg/ml; postoperative, 86?±?220 vs. 62?±?91 pg/ml). Patients with cinacalcet preoperatively had significant lower Ca levels preoperatively (2.49?±?0.25 vs. 2.61?±?0.24 mmol/l) and postoperatively (1.75?±?0.37 vs. 1.86?±?0.35 mmol/l) and had a higher rate of oral Ca substitution postoperatively (93 vs. 74 %). The risk for postoperative persistent disease was slightly higher in these patients compared to those without preoperative cinacalcet therapy (5 vs. 0 %, not significant).

Conclusions

In our experience, cinacalcet did not alter the perioperative course in SHPT patients.     

Long-Term Outcomes of Laparoscopic Surgery for Advanced Transverse Colon Cancer

Background

The role of laparoscopic surgery for advanced transverse colon cancer (TCC) remains controversial, especially in terms of long-term oncologic outcomes.

Methods

This retrospective cohort study enrolled 157 consecutive patients who underwent curable resections for advanced TCC between January 2002 and June 2011 (laparoscopic-assisted colectomy (LAC), n?=?74; open colectomy (OC), n?=?83). Short-term outcomes and oncologic long-term outcomes were compared between the two groups.

Results

Compared to the OC group, patients in the LAC group had less blood loss (LAC vs. OC, 79.6?±?70.3 vs. 158.4?±?89.3 ml, p?<?0.001), faster return of bowel function (2.6?±?0.7 vs. 3.8?±?0.8 days, p?<?0.001), and shorter postoperative hospital stay (10.3?±?3.7 vs. 12.6?±?6.0 days, p?=?0.007). Conversions were required in four (5.4 %) patients. Rates of short-term complication, mortality, and long-term complication were comparable between the two groups. The median follow-up time was 54 (26–106) months in the LAC group and 58 (29–113) months in the OC group (p?=?0.407). There were no statistical differences in the rates of 5-year overall survival (73.6 vs. 71.1 %, p?=?0.397) and 5-year disease-free survival (70.5 vs. 66.7 %, p?=?0.501) between the two groups.

Conclusions

Laparoscopic surgery for advanced TCC yield short-term benefits while achieving equivalent long-term oncologic outcomes.     

Evaluating the porcine dermis graft InteXen® in three-compartment transvaginal pelvic organ prolapse repair

Introduction and hypothesis

The aim was to assess the efficacy of three-compartment pelvic organ prolapse (POP) vaginal repair using the InteXen® biocompatible porcine dermal graft as compared to traditional colporrhaphy with sacrospinous ligament suspension.

Methods

Preoperative, operative, postoperative and follow-up data were collected retrospectively. Objective recurrence was defined as POP quantification ≥ stage II and subjective recurrence as a symptomatic bulge.

Results

Each group consisted of 63 patients. Surgery time was longer using InteXen® (72?±?24.5 vs 55?±?23.5 min, p?=?0.0002). Length of hospital stay (4.6?±?1.6 vs 4.9?±?2.1 days, p?=?0.34) as well as duration of follow-up (37.1 vs 35.7 months, p?=?0.45) were equivalent between the two groups. No case of mesh erosion or infection was noted. The objective (17% vs 8%, p?=?0.12) and subjective recurrence rates (13% vs 5%, p?=?0.12) between the two groups were not statistically different.

Conclusions

InteXen® was well tolerated but had similar efficacy to traditional colporrhaphy and sacrospinous ligament suspension.     

Assessment of delayed gastric emptying after major hepatectomy using a 13C-acetic acid breath test

Purposes

Delayed gastric emptying (DGE) after hepatectomy affects the quality of life of patients, although the causes and related conditions have not been investigated. This study evaluated the relationship between hepatectomy and DGE by the objective assessment of gastric emptying (GE).

Methods

Nineteen patients who underwent major hepatectomy were prospectively enrolled in the study. Their GE was studied using the ¹³C-acetic acid breath test before and after hepatectomy. The results of the GE analysis were correlated with the postoperative course after hepatectomy.

Results

Clinically evident DGE, which was defined as the inability to take in an appropriate amount of solid food orally by postoperative day 14, was not found in these patients, but the gastric half-emptying times before and after hepatectomy were 20.2?±?9.7 and 28.6?±?12.2?min, respectively (P?=?0.01). The GE time was significantly delayed in patients aged ≥41?years, or who underwent right hemihepatectomy.

Conclusions

Gastric emptying was significantly inhibited in patients who underwent major hepatectomy, and aging and a right-sided hemihepatectomy may be related to the development of DGE.     

Transvaginal electrical stimulation with surface-EMG biofeedback in managing stress urinary incontinence in women of premenopausal age: a double-blind, placebo-controlled, randomized clinical trial

Introduction and hypothesis

The aim of this study was to evaluate the results of conservative treatment of urodynamic stress urinary incontinence (SUI) using transvaginal electrical stimulation with surface-electromyography-assisted biofeedback (TVES?+?sEMG) in women of premenopausal age.

Methods

One hundred and two patients with SUI were divided into two groups: active (n?=?68) and placebo (n?=?34) TVES?+?sEMG. The treatment lasted for 8 weeks and consisted of two sessions per day. Women were evaluated before and after the intervention by pad test, voiding diary, urodynamic test, and the Incontinence Quality of Life Questionnaire (I-QOL).

Results

Mean urinary leakage on a standard pad test at the end of 8th week was significantly lower in the active than the placebo group (19.5?±?13.6 vs. 39.8?±?28.5). Mean urinary leakage on a 24-h pad test was significantly reduced in the active group at the end of 8th and 16th weeks compared with the placebo group (8.2?±?14.8 vs. 14.6?±?18.9 and 6.1?±?11.4 vs. 18.2?±?20.8, respectively). There was also a significant improvement in muscle strength as measured by the Oxford scale in the active vs the placebo group after 8 and 16 weeks (4.2 vs 2.6 and 4.1 vs 2.7, respectively). No significant difference was found between groups in urodynamic data before and after treatment. At the end of 8th week, the mean I-QOL score in the active vs the placebo group was 78.2?±?17.9 vs 55.9?±?14.2, respectively, and at the end of 16th week 80.8?±?24.1 vs. 50.6?±?14.9, respectively.

Conclusion

Our study showed that TVES?+?sEMG is a trustworthy method of treatment in premenopausal women with SUI; however, its reliability needs to be established.     

Does lean tissue mass accrual during adolescence influence bone structural strength at the proximal femur in young adulthood?

Summary

The purpose of this study was to identify whether young adult bone structural strength at the hip is associated with adolescent lean tissue mass (LTM) accrual. It was observed that those individuals who accrued more LTM from adolescence to adulthood had significantly greater adult bone structural strength at the hip.

Introduction

The purpose of this study was to identify whether young adult bone cross-sectional area (CSA), section modulus (Z), and outer diameter (OD) at the hip were associated with adolescent LTM accrual.

Methods

One hundred three young adult participants (55 males, 48 females) were tertiled into adolescent LTM accrual groupings. LTM accrual was assessed by serial measures using dual energy X-ray absorptiometry (DXA) from adolescence to young adulthood (21.3?±?1.3 years). CSA, Z, and OD at the narrow neck (NN) and femoral shaft (S) sites of the proximal femur were assessed in young adulthood (21.3?±?4.5 years), using hip structural analysis. Group differences were assessed using an analysis of covariance, controlling for adult height, weight, sex, and physical activity levels.

Results

It was found that individuals with higher adjusted adolescent LTM accrual had significantly greater adult adjusted values of NNCSA (2.49?±?0.06 vs 2.77?±?0.07 cm²), NN Z (1.18?±?0.04 vs 1.37?±?0.04 cm³), NN OD (3.07?±?0.04 vs 3.21?±?0.04 cm), SCSA (3.45?±?0.08 vs 3.88?±?0.09 cm³), and SZ (1.77?±?0.05 vs 2.00?±?0.05 cm³) than individuals with lower LTM accrual (p?<?0.05).

Conclusions

These findings suggest that the amount of LTM accrued from adolescence to young adulthood has a positive influence on adult bone structural strength at the proximal femur.     

Braun Gastrointestinal Bypass Surgery Exerts Similar Hypoglycemic Effects, with Minimal Operation Time and Earlier Functional Recovery, than Roux-en-Y Bypass in Type 2 Diabetic Rats

Background

Despite the beneficial hypoglycemic and potentially curative effects in type 2 diabetes, large stomach volume deficits caused by Roux-en-Y gastrointestinal bypass (RYGB) surgery increase complications. Hypoglycemic effects of Braun surgery and RYGB surgery, both modified to maximally preserve stomach volume, were compared in rat type 2 diabetes models.

Methods

Three-month-old, male Goto-Kakizaki (GK) rats (n?=?40) were randomly divided into equal groups and not treated (control) or treated with sham surgery (sham group), modified stomach-preserving Braun gastrointestinal bypass (Braun group), or modified RYGB (RYGB group). Pre- and postoperative body weight and water intake were recorded, along with operative and defecation times. Fasting blood glucose at 12 h, and blood glucose 180 min after intragastric glucose administration, were measured at weeks 1, 2, 3, 4, 10, and 11 along with glycosylated hemoglobin (preoperatively, week 11).

Results

Statistically similar (P?>?0.05) increased body weight and decreased water intake, fasting blood glucose, blood glucose after intragastric glucose administration, and glycosylated hemoglobin were observed in Braun and RYGB groups compared with control and sham groups (P?<?0.05). By week 1, RYGB and Braun groups exhibited sustained reductions in fasting blood glucose from 13.0?±?4.1 to 6.9?±?1.4 mmol/L and 12.4?±?4.4 to 7.3?±?0.9 mmol/L, respectively (P?<?0.05); mean operative times were 139.1?±?4.9 and 81.6?±?6.4 min, respectively; and postoperative defecation times were 74.3?±?3.1 and 29.4?±?4.1 h, respectively (P?<?0.05).

Conclusions

Stomach volume-preserving Braun gastrointestinal bypass surgery was faster and produced hypoglycemic effects similar to RYGB bypass surgery, potentially minimizing metabolic disruption.     

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.

     

The Role of Gender in Primary Hyperparathyroidism: Same Disease, Different Presentation

Background

Hyperparathyroidism is much more common in women and therefore may represent different diseases in men and women. In order to understand the role of gender in hyperparathyroidism, we reviewed our experience.

Methods

We analyzed a prospective database of 1309 consecutive patients with primary hyperparathyroidism who underwent parathyroidectomy at our institution between March 2001 and August 2010.

Results

The female-to-male ratio was 3.3:1, and female patients were older at presentation (60?±?0 vs. 57?±?1?years, p?p?=?0.005) and the most common symptom for men was kidney stones (23?% vs. 13?%, p?p?p?=?0.03), higher parathyroid hormone level (140?±?7 vs. 124?±?4?pg/ml, p?=?0.04), higher urinary calcium level (376?±?10 vs. 314?±?5?mg/24?h, p?p?p?=?0.004). The operative approach as well as the number of glands involved and their location did not significantly differ between the groups. The mean gland weight for a single adenomas was higher in male patients (1123?±?128 vs. 636?±?32?mg, p?=?0.001). No significant difference was identified in the immediate and remote postoperative course.

Conclusions

Hyperparathyroidism appears to present differently depending on gender. Male patients more often present without symptoms, present with vitamin D deficiency, and have larger parathyroid glands. Importantly, surgical outcomes were equivalent between men and women.     

Normal sagittal of the anterior cruciate ligament can be reproduced using accessory anteromedial portal technique: a magnetic resonance imaging study

Introduction

Over time, the need for anatomic anterior cruciate ligament (ACL) to restore normal kinematics and postoperative function of the knee has been accepted. The purpose of this study was to compare the sagittal alignment of reconstructed ACL, which is performed between transtibial (TT) technique and accessory anteromedial (AAM) portal technique and between the reconstructed and the normal side in the same patient. In addition, we used the head of a metallic femoral interference screw as a reference to measure the femoral tunnel position.

Patients and methods

This was a retrospective study with 15 patients in each group: accessory anteromedial portal technique (n?=?15), TT technique (n?=?15) and contralateral normal side of each technique group (15 knees per technique). Magnetic resonance images of the ACL sagittal angle and radiographs of the coronal screw angle were used for comparing the two groups. The paired t test was used to compare operated and contralateral normal knee and independent t test was used to compare the TT and the AAM groups.

Results

The sagittal angle of ACL of AAM technique (51.6?±?3.3°) was not different from the normal side (50.8?±?2.1°) (P?=?0.270), however that of the TT technique (59.9?±?5.7°) was significantly different from the normal side (50.9?±?2.4°) (P?P?P?Conclusion The anatomic sagittal angle of ACL can be achieved using the AAM technique compared with the TT technique. In addition, the angle of the screw in coronal plane was more horizontal using the AAM technique than with use of the TT technique.

Level of evidence

Level III, diagnostic study.     

Minimalinvasive,videoassistierte Schilddrüsenresektion

Background

This study retrospectively evaluated a series of patients who underwent minimally invasive video-assisted thyroidectomy (MIVAT) during the introduction stage of this surgical technique at the Martha-Maria Hospital in Nuremberg.

Patients and methods

The eligibility criteria for MIVAT were a thyroid volume <?25 ml, nodules <?30 mm, no thyroiditis, no preoperative evidence of carcinoma and no previous neck surgery. A retrospective evaluation was performed together with a control group of patients who underwent conventional thyroid surgery during the same time period and included a follow-up for general patient satisfaction and cosmetic results.

Results

Between August 2008 and July 2009 a total of 55 patients underwent MIVAT including 8 conversions to open surgery and 45 patients who underwent conventional surgery served as matched controls. No significant differences in terms of perioperative complication rates were found (e.g. recurrent laryngeal nerve palsy, hypocalcemia or secondary hemorrhage). The mean operating time was significantly longer in the MIVAT group (96.8?±?3.7 min vs. 69.8?±?2.3 min, p?=?0.001) whereas a significant decrease in the mean operating time for hemithyroidectomy after 5 months was observed (98.1?±?3.77 min vs. 76.0?±?4.98 min, p?=?0.013). Patients in the MIVAT group were more satisfied with the cosmetic outcome (8.5?±?0.3 vs. 8.2?±?0.2, p?=?0.05) as well as with the overall surgical procedure (9.0?±?0.3 vs. 8.6?±?0.2, p?=?0.02).

Conclusion

During introduction of the MIVAT procedure a learning effect can be observed which is hallmarked by a decrease in operating time and conversion rate to open surgery. Moreover, no significant differences in terms of main postoperative complications were found so that MIVAT can be considered a safe and feasible technique under the conditions of correct eligibility criteria.     

Zoledronic acid results in better health-related quality of life following hip fracture: the HORIZON�CRecurrent Fracture Trial

Summary

This study evaluated the benefits of ZOL versus placebo on health-related quality of life (HRQoL) among patients from HORIZON?CRFT. At month?24 and end of the study visit, ZOL significantly improved patients?? overall health state compared to placebo as assessed by the EQ-5D VAS.

Introduction

To evaluate the benefits of zoledronic acid (ZOL) versus placebo on health-related quality of life (HRQoL) among patients from The Health Outcomes and Reduced Incidence With Zoledronic Acid Once Yearly Recurrent Fracture Trial (HORIZON?CRFT).

Methods

In this randomized, double-blind, placebo-controlled trial, 2,127 patients were randomized to receive annual infusion of ZOL 5?mg (n?=?1,065) or placebo (n?=?1,062) within 90?days after surgical repair of low-trauma hip fracture. HRQoL was measured using EQ-5D Visual Analogue Scale (VAS) and utility scores (EuroQol instrument) at months?6, 12, 24, 36, and end of the study visit. Analysis of covariance model included baseline EQ-5D value, region, and treatment as explanatory variables.

Results

At baseline, patients (mean age 75?years; 24% men and 76% women) were well matched between treatment groups with mean EQ-5D VAS of 65.82 in ZOL and 65.70 in placebo group. At the end of the study, mean change from baseline in EQ-5D VAS was greater for ZOL vs. placebo in all patients (7.67?±?0.56 vs. 5.42?±?0.56), and in subgroups of patients experiencing clinical vertebral fractures (8.86?±?4.91 vs. ?1.69?±?3.42), non-vertebral fractures (5.03?±?2.48 vs. ?1.07?±?2.16), and clinical fractures (5.19?±?2.25 vs. ?0.72?±?1.82) with treatment difference significantly in favor of ZOL. EQ-5D utility scores were comparable for ZOL and placebo groups, but more patients on placebo consistently had extreme difficulty in mobility (1.74% for ZOL vs. 2.13% for placebo; p?=?0.6238), self-care (4.92% vs. 6.69%; p?=?0.1013), and usual activities (10.28% vs. 12.91%; p?=?0.0775).

Conclusion

ZOL significantly improves HRQoL in patients with low-trauma hip fracture.     

Feasibility and safety of transglottic bronchoscopy in mechanically ventilated sheep

Purpose

Although bronchoscopy can be safely performed through endotracheal tube in most intubated critically ill patients, sometimes it could lead to complications such as hypoxia and high airway pressures. Theoretically, transglottic bronchoscopy (TGB) does not interfere with mechanical ventilation and could avoid these complications. In a two-period crossover study, we compared this technique with trans-endotracheal tube bronchoscopy (TEB) in normal anesthetized sheep.

Methods

In five sheep, we did TGB first. The bronchoscope was introduced through the nasal nares and passed into the trachea via space between endotracheal tube and vocal folds. Heart rate, V _T, P _peak, and O₂ saturation were recorded. One week later, we did TEB. In another five sheep, we did TEB first and TGB later.

Results

P _peak increased and V _T and O₂ saturation decreased during TEB (53.2?±?5.7 vs. 27.6?±?0.6, P?=?0.002; 210?±?32 vs. 285?±?26, P?=?0.002; 94.3?±?1.3 vs. 97.5%?±?0.5, P?=?0.041, respectively), but not during TGB. The only statistically significant abnormal finding during TGB was a mild tachycardia (96.7?±?5.7 vs. 94.7?±?5.5, P?=?0.034).

Conclusion

Although TGB is time consuming and less convenient than TEB, it has minimal interference with mechanical ventilation. Expertise with this technique could be useful in patients with anticipated significant hypoxia and high airway pressures during bronchoscopy.