Neuromuscular monitoring: does it make a difference?

Purpose

The objective of the present prospective study was to evaluate the influence of neuromuscular monitoring. on the level of neuromuscular blockade from induction of anaesthesia until extubdtion of the trachea.

Methods

Forty-two patients aged between 18 and 73 yr undergoing a range of surgical procedures under general anaesthesia were randomly distributed into two groups of 21 patients each. In both groups a Datex NMT Monitor® was used and electromyographic responses of the the ulnar muscles to supramaximal stimulation of the ulnar nerve were recorded. In Group 1, the anaesthetist could see the movements of the stimulated hand, but not the monitor. In Group 2, the anaesthetist could see neither the stimulated hand nor the monitor. The same anaesthetist administered the neuromuscular relaxants which were succinylcholine 1.5 mg · kg^?1 for trachéal intubation and vecuronium 0.1 mg· kg^?1 for neuromuscular relaxation during surgery, followed by 1 to 2 mg maintenance injections. Possible residual curarization was evaluated in the recovery room by head lift tests and pulse oximetry.

Results

Patients in Group 1 had deeper neuromuscular block throughout surgery, despite the use of a comparable dose of vecuronium (10.1 mg for G1 vs 11.2 mg for G2). The EMG values of T₁ and train-of-four values were not different at trachéal intubation or at extubation. No patients presented signs of residual curarization in the recovery room.

Conclusion

The study demonstrates that with the same amount of vecuronium the neuromuscular relaxation was deeper with the use of a simple neuromuscular monitoring (visual evaluation of the thumb movements). Despite the deeper neuromuscular block in the monitored group, there was no residual curarization in the recovery room.     

Does a short-stemmed humeral implant really make a difference?

Total shoulder arthroplasty (TSA) for the treatment of osteoarthritis has shown excellent pain relief with durable outcomes. The trend toward less-invasive shoulder surgery and preservation of as much normal anatomy has led to the development of short-stem humeral implants. This technology helped in reducing stress shielding and facilitation of revision surgeries. With limited literature on stemless humeral implants, emerging studies have shown favorable outcomes and ease of use compared to traditional implants. Future analysis and assessment of new short-stem implant designs is warranted.     

Pre–Lap-Band group education in Medicaid population: does it really make a difference?

BackgroundThe effect of group education classes before a Lap-Band procedure has not been well defined. We hypothesized that in a Medicaid population, the completion of a standardized 12-week multidisciplinary preoperative program (SMPP) would significantly improve the preoperative and early postoperative weight loss. All procedures were performed at a University-affiliated community hospital from 2006 to 2007.MethodsA prospectively collected database of 292 patients who underwent Lap-Band placement was retrospectively reviewed. All patients in the study cohort were encouraged to participate in the SMPP, which included medical, psychological, and nutritional interventions. The patients were divided into 2 groups according to their participation in the SMPP program: SMPP compliant and non-SMPP compliant. The postoperative weight loss of these 2 groups was then compared using the general linear models for repeated measures statistical analysis.ResultsNo significant difference was found in the mean baseline excess body weight between the 2 groups (74 ± 20 kg in the SMPP-compliant and 76 ± 20 kg in the non–SMPP-compliant participants). The mean baseline body mass index (47 ± 7 versus 48 ± 72 kg/m² for the SMPP-compliant and non–SMPP-compliant participants) was also similar in the 2 groups. The postoperative follow-up rate was 94.5% at 1 month, 72.3% at 6 months, and 52.7% at 12 months. The excess weight loss was significantly greater in the SMPP compliant group than in the noncompliant group during the observed 12-month follow-up period (P = .04, by general linear models for repeated measures).ConclusionIn a Medicaid population, implementation of an intensive preoperative SMPP resulted in a significant improvement in the short-term weight loss after Lap-Band placement.     

Anastomotic technique—Does it make a difference?

The morbidity and mortality associated with anastomotic leak (AL) can be severe. Surgeons have long sought to refine the technical aspects of constructing anastomoses with the goal of lowering incidence of AL. Anastomotic technique is aimed at creating a well-perfused, tension-free anastomosis. Anastomoses can performed using hand-sewn technique or with surgical staplers. There are many variations in the hand-sewn technique, such as the type of suture material used, the number of layers and whether the bowel is inverted or everted. The introduction of surgical staplers has altered the technical ease of constructing anastomoses, and this has contributed to their widespread clinical use. However, stapled anastomoses have not proven to be superior to hand-sewn anastomoses in the development of AL. Many other factors have been studied, such as anastomotic configuration (end-to-end, side-to-end, straight coloanal, colonic J-pouch, or transverse coloplasty), high versus low ligation of the inferior mesenteric artery ligation, omentoplasty, and prophylactic drain placement, but none have consistently been shown to prevent the development of AL.     

American College of Surgeons,Committee on Trauma Verification Review: does it really make a difference?

BACKGROUND: Although not directly involved in designation per se, the American College of Surgeons (ACS) Committee on Trauma verification/consultation program in conjunction with has set the national standards for trauma care. This study analyzes the impact of a recent verification process on an academic health center. METHODS: Performance improvement data were generated monthly from the hospital trauma registry. Forty-seven clinical indicators were reviewed. Three study periods were defined for comparative purposes: PRE (January, June, October 1997), before verification/consultation; CON (April 1999-October 1999), after reorganization; and VER (November 1999-September 2000), from consultation to verification. RESULTS: Statistically significant (p < 0.05) quantitative and qualitative changes were observed in numbers (percent) of patients reaching clinical criteria. These included prehospital, emergency department, and hospital-based trauma competencies. Trauma patient evaluation (including radiology) and disposition out of the emergency department (< 120 minutes) improved in each study section (PRE, 21%; CON, 48%; VER, 76%). Enhanced nursing documentation correlated with improved clinical care such as early acquisition of head computed axial tomographic scans in neurologic injured patients (PRE, 66%; CON, 97%; VER, 95%). Intensive care unit length of stay (< 7 days) decreased (PRE, 87%; VER, 97.8%). Other transformations included increase in institutional morale with recognition of trauma excellence within the hospital and resurgence of the trauma research programs (60 institutional review board-approved projects). CONCLUSION: The ACS verification/consultation program had a positive influence on this developing academic trauma program. Preparation for ACS verification/consultation resulted in significant improvements in patient care, enhancement of institutional pride, and commitment to care of the injured patient.     

Knowing patients' preferences about organ donation: does it make a difference?

BACKGROUND: The purpose of this study was to examine in detail the impact of knowledge of a donor-eligible patient's preferences on organ donation decisions. METHODS: Nine trauma hospitals located in southwest Pennsylvania and northeast Ohio were selected. Data came from chart review of all dead patients and interviews with family members involved in the decision process (n = 360 patients 16 years of age or older). RESULTS: Of the families interviewed, 52.5% had to guess the patient's preferences about donation. When making the decision, 81.9% of the families considered how the patient might have felt about donation. Not knowing the patient's wishes related to refusal to donate (54.5% vs. 45.5%, p < 0.001). After adjusting for other factors, important predictors of donation were considering patients' feelings (5.03 times more likely to donate) and knowing preferences (6.90 times more likely to donate if they knew wishes were to donate and 0.03 times less likely to donate if they knew wishes were to not donate compared with not knowing preferences). CONCLUSION: Having knowledge of a patient's preference to donate increased the likelihood of donating by 6.90 times, and having enough information about the patient's wishes increased satisfaction with the decision by 3.32 times. Families only infrequently made decisions counter to patients' own wishes concerning organ donation.     

Surgical clerkship or medical clerkship first: Does it make a difference?

Introduction

This study compares NBME surgical clerkship scores of students who completed their medicine clerkship before their surgical clerkship with the performance of those who had not previously completed their medical clerkship.

Extended lymph node dissection in patients with urothelial cell carcinoma of the bladder: can it make a difference?

Objective  We compared extended and limited lymph node dissections performed during radical cystectomy with regard to impact on survival and time to recurrence in bladder cancer patients. Methods  We analyzed 170 patients who underwent radical cystectomy for urothelial carcinoma between January 1997 and December 2005. From 1997 to 2000, 69 of the patients were subjected to limited lymph dissection that included perivesical nodes and nodes in the obturator fossa. In 2001–2005, the remaining 101 patients underwent extended lymph dissection that included perivesical nodes; nodes in the obturator fossa; the internal, external, and common iliac nodes; and the presacral nodes. Results  Tumors penetrating the bladder wall (pT3 and pT4a) were more common in the extended than in the limited dissection group (48 and 33%, respectively). The median numbers of lymph nodes removed in the two groups were 37 and 8, respectively. Lymph node metastases were detected in 38% of the extended dissection patients but only in 17% of the limited dissection patients. There was no significant difference in survival or time to recurrence between the two groups. Subgroup analyses showed a significantly longer time to recurrence (HR 0.45, 95% CI 0.22–0.93; P = 0.032) in patients with non-organ-confined disease who underwent extended lymph node dissection. In a multivariate analysis adjusting for tumor stage, lymph node status, age, sex, and adjuvant chemotherapy, there was a significantly improved survival (HR 0.47, 95% CI 0.25–0.88; P = 0.018) and time to recurrence (HR 0.42, 95% CI 0.23–0.79; P = 0.007) in the patients with extended lymph node dissections. Conclusions  Extended lymph node dissection did not improve disease-specific survival, but was in multivariate analysis related to significantly improved disease-specific survival and prolonged time to recurrence in radical cystectomy patients. These results should be interpreted cautiously, since they might have been affected by stage migration and the shorter follow-up in the extended dissection group.     

Plastic surgery in a day surgery unit: 1 year’s experience

The study is of the different pathologies treated at the UCSI by a Plastic Surgery Unit during the course of a year. Variables such as age, sex, pathology and degree of patient satisfaction have been studied. The total number of patients treated was 678. The most common surgery was for skin tumours and hand pathology. Of those treated 96% demonstrated a high degree of satisfaction.     

Anatrophic nephrolithotomy: is it really an obsolete procedure?

Since the introduction of extracorporeal shock wave lithotripsy and the various modalities of endoscopic surgery, the number of open procedures for the treatment of urolithiasis has decreased dramatically. The use of these techniques in the management of easier cases leaves no doubt, but there is still some controversy about what should be the best treatment option for the largest and most complex staghorn calculi. Anatrophic nephrolithotomy is still considered the gold standard for the treatment of such lithiasis. This paper presents in detail the key technical points to consider during its performance.     

Functional outcomes and clinical strength assessment after infraspinatus-sparing surgical approach to scapular fracture: Does it really make a difference?

Background

Surgical treatment of scapular fractures with posterior approach is frequently associated with postoperative infraspinatus hypotrophy and weakness. The aim of this retrospective study is to compare infraspinatus strength and functional outcomes in patients treated with the classic Judet versus modified Judet approach for scapular fracture.

Patients and methods

20 cases with scapular neck and body fracture treated with posterior approach for lateral border plate fixation were reviewed. In 11 of 20 cases, we used the modified Judet approach (MJ group), and in 9 cases we used the classic Judet approach (CJ group). All fractures were classified according to the AO classification system. At follow-up examinations, patients had X-ray assessment with acromiohumeral distance (AHD) measurement, clinical evaluation, active range of motion (ROM) examination, Constant Shoulder Score, and Disability of the Arm, Shoulder and Hand (DASH) Score. Infraspinatus strength assessment was measured using a dynamometer during infraspinatus strength test (IST) and infraspinatus scapular retraction test (ISRT).

Results

Demographic data did not significantly differ between the CJ group and MJ group, except for mean follow-up, which was 4.15 years in the CJ group and 2.33 in the MJ group (p < 0.001). All X-ray examinations showed fracture healing. AHD was significantly decreased in the CJ group (p = 0.006). We did not find significant differences in active ROM between the MJ and CJ groups in the injured arm (p < 0.05). The Constant Score was 75.83 (±14.03) in the CJ group and 82.75 (±10.72) in the MJ group (p = 0.31); DASH Score was 10.16 in the CJ group and 6.25 in the MJ group (p = 0.49). IST showed mean strength of 8.38 kg (±1.75) in the MJ group and 4.61 kg (±1.98) in the CJ group (p = 0.002), ISRT test was 8.7 (±1.64) in the MJ group and 4.95 (±2.1) in the CJ group (p = 0.002). Infraspinatus hypotrophy was detected during inspection in six patients (five in the CJ group and one in the MJ group); it was related to infraspinatus strength weakness in IST and ISRT (p < 0.001).

Conclusions

Infraspinatus-sparing surgical approach for scapular fracture avoids infraspinatus hypotrophy and external-rotation strength weakness. We suggest use of the modified Judet approach for scapular fracture and to restrict the classic Judet approach to only when the surgeon believes that the fracture is not easily reducible with a narrower exposure.

Level of evidence

Level IV.

     

Narcotrend-assisted propofol/remifentanil anaesthesia vs clinical practice: does it make a difference?

BACKGROUND: The Narcotrend is a computer-based EEG monitor designed to measure the depth of anaesthesia. The aim of the present study is to test the hypothesis that the intraoperative level of anaesthetic depth differs if decision-making is guided by Narcotrend monitoring or not. METHODS: Forty-eight patients undergoing elective surgery were randomized to receive a Narcotrend-controlled propofol/remifentanil anaesthetic regimen or standard clinical practice. In the EEG group, anaesthesia was adjusted to achieve a Narcotrend level of D2-E0, which is recommended for moderate to deep anaesthetic depth for surgery. EEG values were recorded continuously every 20 s in both groups. Depending on data distribution, group comparisons of the EEG parameters, propofol plasma concentration, and recovery characteristics were performed by analysis of variance for repeated measurements or non-parametric statistics. RESULTS: About 62 (sd 29)% of the Narcotrend values were within the target level in the EEG group during maintenance of anaesthesia; this was true for 64 (26)% of the data in the non-EEG group. The variance of the Narcotrend data was significantly lower in the EEG group compared with the non-EEG group [median: 0.4 (range: 3.5) vs 0.6 (2.5); P = 0.048]. There was no difference in propofol or remifentanil dosage, propofol plasma concentrations, and time for extubation. Ten minutes after extubation, visual analogue scores for nausea indicated a lower incidence in the Narcotrend group [7 (15) vs 24 (34); P = 0.005]. CONCLUSIONS: Guidance of anaesthesia with the Narcotrend-monitor leads to fewer deviations from a defined target than clinical assessment of anaesthetic depth only. This results in lower scores of nausea in the immediate period after anaesthesia.     

Trunnionosis: Is it really a problem?

Corrosion between the modular head and neck interface of uncemented femoral components was initially seen in retrieval studies of total hip implants in the mid- to late-1980s, but clinical symptoms related to these findings were relatively rare. Over the past 5–7 years, there has been a re-emergence of corrosion of the head–neck junction as an important symptomatic clinical entity and cause of revision of metal-on-polyethylene total hip arthroplasty. Trunnion or taper corrosion may be a multifactorial process, involving implant design, surgical technique, and patient characteristics. The clinical presentation of trunnion corrosion is variable and requires a high index of suspicion. Serum levels of cobalt and chromium ions and cross-sectional imaging are usually required to confirm the diagnosis. Treatment is revision surgery with femoral head exchange to a noncobalt–chromium alloy component. Complications after this procedure may be more frequent than expected.     

Surgeons’ experience with laparoscopic fundoplication after the early personal experience: does it have an impact on the outcome?

Background The adverse outcomes of laparoscopic fundoplication are more likely during the initial 20 cases performed by each individual surgeon. This study aimed to evaluate the impact of substantial surgical experience versus experience beyond the learning curve on the early and late objective and subjective results. Methods The patients were divided into two groups according to the surgeon. In group 1 (n = 230), all the patients underwent surgery by a surgeon with substantial experience in laparoscopic fundoplication. In group 2 (n = 118), the patients were treated by a total of seven surgeons whose personal experience exceeded the individual learning curve, but was distinctively less than that of the group 1 surgeon. Results The conversion rate was 2.2% in group 1 and 4.4% in group 2. The median operating time was 65 min in group 1 and 70 min in group 2 (p = 0.0020). The occurrence of immediate complications was 3.5% in group 1 and 7.6% in group 2 (p = 0.0892). At 6 months after surgery, 7.4% of the patients in group 1 and 16.1% of the patients in group 2 reported that dysphagia disturbed their daily lives (p = 0.0115). The late subjective results, including postoperative symptoms and evaluation of the surgical result, were similar in the two groups. Conclusions Substantial experience with the procedure is associated with a shorter operating time and somewhat fewer complications, conversions, and early dysphagia episodes. This supports the provision of expert supervision even after the initial learning phase of 20 individual procedures. The patients’ long-term subjective symptomatic outcome was similar in the two groups. Substantial experience does not provide better late results than surgical experience beyond the learning curve.