Laparoscopic surgery for inflammatory bowel disease: does weight matter?

Background  

Recent studies have shown improved outcomes after laparoscopic colorectal surgery compared with laparotomy for surgery for both benign and malignant colorectal diseases, including inflammatory bowel disease (IBD). This study was designed to evaluate the results of laparoscopic colorectal resections in normal weight patients compared with overweight and obese patients with IBD.     

Laparoscopic splenectomy in patients with normal-sized spleens versus splenomegaly: does size matter?

Laparoscopic resection has become the standard means for removal of normal-sized spleens in many medical centers. The application of minimally invasive techniques in the setting of splenomegaly is less well defined and was previously considered a contraindication to the laparoscopic approach. The purpose of this prospective study of consecutive patients was to compare the outcomes of patients undergoing laparoscopic splenectomy for normal-sized spleens (150 g or less) versus those with clear evidence of splenomegaly (500 g or greater). One hundred forty-two patients met the inclusion criteria. The most common diagnosis in the normal-sized spleen group was idiopathic thrombocytopenia purpura (67 of 82, 82%). Malignant hematologic diseases (lymphoma and leukemia) were the most common diagnoses in the splenomegaly group (35 of 60, 58%). Mean operative times (127 vs 172 minutes) and estimated blood loss (123 vs 173 cm3) were lower for those patients with normal-sized spleens (P < 0.05). There were no statistical differences in conversion rates, lengths of stay, or complications between the two groups. We conclude that laparoscopic splenectomy is safe and effective in the setting of splenomegaly despite modest but statistically longer operative times and increased operative blood loss when compared with laparoscopic splenectomy for normal-sized spleens.     

Laparoscopic ventral hernia repair in the elderly: does the type of hernia matter?

Purpose

Assess the impact of age and type of hernia on the outcomes of laparoscopic ventral hernia repair (LVHR).

Methods

Operating room database of all laparoscopic ventral hernias performed from April 2001 to July 2010 was analyzed retrospectively. Patients were divided into two groups: primary hernias (Group 1) and incisional hernias (Group 2). These groups were further stratified into patients <65?years of age (Groups 1A and 2A) and patients >65?years of age (Groups 1B and 2B). Patient demographics, hernia characteristics, perioperative outcomes, and disposition at discharge were compared. p-values <0.05 were considered significant.

Results

325 patients, with a mean age of 56.6?years (24–93?years) underwent LVHR. The mean length of stay (LOS) was longer (2.7?days vs 1.7?days, p value?=?0.02), and the rate of same day discharge was also significantly lower (12 vs. 25?%, p?=?0.02) for Group 2B when compared to Group 2A. Three patients in Group 2B, who had been living independently, were discharged to a skilled nursing facility, which proved significantly different when compared with Group 2A. There was no statistically significant difference in perioperative outcomes between younger and older subgroups with primary hernias.

Conclusions

LVHR in the elderly with incisional hernias have longer LOS and have a higher need for post-discharge nursing care unlike their counterparts with primary hernias. Identifying this cohort of patients early on helps the health-care providers to optimize the outcomes.     

Renal ischemia: does sex matter?

Renal ischemia is a common complication in the perioperative period that leads to a high rate of morbidity and mortality. As in other forms of ischemia (i.e., cardiac, neurologic), the incidence and outcome of renal ischemia is strikingly sex-specific. Sexual dimorphism in response to renal injury has been noted for many years, but is now the subject of both clinical and experimental research. Clinically, women experience a lower incidence of perioperative acute renal failure, with the exception of cardiac surgery. Experimental science is now producing tantalizing clues that sex steroids, both male and female, play a role in the kidney's response to ischemia. In this review, we evaluated sex differences in perioperative renal failure and in the pathophysiology of renal ischemia/reperfusion injury. Although much work remains to characterize the biological mechanisms involved, the data are sufficient to support consideration of gender and the use of medications that impact steroid availability in the perioperative plan of care.     

Coccygectomy for coccygodynia: does pathogenesis matter?

BACKGROUND: Severity of vertical impact to the coccyx can range from mere contusion to a dislocated fracture of the coccyx. With early conservative management, most patients have a good prognosis and heal within weeks to months after the initial trauma. Occasionally, persisting symptoms make a surgical intervention with coccygectomy necessary. METHODS: We report on the results of patients surgically managed for traumatically induced, persisting coccygodynia and compare these to patients operatively treated for idiopathic coccygodynia. Sixteen patients with an average follow-up of 7.3 years were evaluated. Of these, eight were surgically treated for traumatic and eight for idiopathic coccygodynia. The clinical results were assessed by means of the Hambly Score and the Oswestry Low Back Pain Disability questionnaire. Patient satisfaction with the postoperative result was assessed by a visual analog scale. RESULTS: Seven of eight (88%) patients treated for traumatically induced coccygodynia had a good or excellent postoperative result, in contrast to only three of eight (38%) patients with idiopathic coccygodynia. The former group had better results in terms of sitting tolerance and general pain intensity as represented by the Oswestry Low Back Pain Disability questionnaire. According to the significantly better clinical results, personal satisfaction was clearly higher in the traumatic group. CONCLUSION: These results suggest that, in patients where all conservative treatment methods work to no avail, particularly those with traumatically induced persisting coccygodynia benefit from surgical intervention with coccygectomy.     

Difficult mask ventilation: does it matter?

We discuss the relevance of finding a patient's lungs difficult to ventilate by facemask during the course of anaesthetic induction. In particular, we discuss the issue of whether it is advisable or unnecessary to check the ability to ventilate by facemask before administering a neuromuscular blocking agent. In the light of advances in supraglottic airway technology it has become possible to insert these devices very soon after induction and in a wider variety of patients. Similarly, the development of videolaryngoscopes and rapidly acting drugs such as rocuronium have raised the possibility of earlier, and possibly more successful, tracheal intubation, with the potential result that mask ventilation becomes redundant. However, we conclude by reaffirming its value in airway management strategies.     

Laryngotracheal injuries: does injury mechanism matter?

Laryngotracheal injuries are potentially lethal injuries whose diagnosis can be difficult. The purpose of this study was to delineate the effect of injury mechanism on the types of injury sustained and patient outcome. Patient records during a 7-year period were reviewed for injury mechanism, patient demographics, clinical presentation, patient evaluation, injury location, associated injuries, operative interventions, and outcome. Fifteen patients with laryngotracheal injuries were studied. Blunt injuries were more common (60%). Patient demographics, mortality, average length of stay, and Injury Severity Score were similar for both groups. Prevalent physical findings on examination included subcutaneous air (53%), hoarseness (47%), stridor (20%), and neck tenderness (27%). Diagnosis was confirmed by CT scan of the neck (66% blunt, 33% penetrating) or bronchoscopy (44% blunt, 66% penetrating). Injury location, patient disposition, and associated injures were the same for both groups. The most frequent operative intervention performed for both groups consisted of a primary airway repair via a collar incision within 8 hours of injury. Only patients with a laryngeal injury required concomitant tracheostomy regardless of mechanism. Blunt and penetrating neck injuries resulted in similar types of tracheal and laryngeal injuries. Anatomic location of the injury determined the need for tracheostomy. Regardless of mechanism, the overall outcome for patients with laryngotracheal injuries is good when injuries are recognized and treated expeditiously. A high level of suspicion must be maintained when evaluating all potential laryngotracheal injury patients irrespective of the mechanism of injury.     

Laparoscopic distal pancreatectomy: does splenic preservation affect outcomes?

Although the spleen is often routinely resected during both open and laparoscopic distal pancreatectomies, a splenectomy can increase the risk of postoperative and life-long infectious complications. Spleen-preserving laparoscopic pancreatectomies can technically be more difficult because of the delicate dissection of the splenic vessels. We performed a retrospective review of 34 laparoscopic pancreatectomies done at our institution. All procedures were done laparoscopically without hand assistance. Attempts were made in all patients to conserve the spleen, which was successful in 10 patients (29%). In the splenectomy group, 9 patients had 12 surgical complications (26%), which was statistically significant compared with the spleen-preserving group, in which there were no complications. This included 7 patients with a pancreatic leak (20%) and 3 with postoperative hemorrhage requiring reexploration (9%). Patients with spleen-preserving pancreatectomies had significantly less blood loss and shorter operative time compared with patients who underwent concomitant splenectomy. Splenic preservation should be attempted in all patients undergoing laparoscopic distal pancreatectomy unless there are overriding oncological or anatomic concerns.     

Establishing hand preference: why does it matter?

Hand preference has been associated with psychological and physical well-being, risk of injury, pathological irregularities, longevity, and cognitive function. To determine hand preference, individuals are often asked what hand they use to write with, or what hand is used more frequently in activities of daily living. However, relying only on one source of information may be misleading, given the strong evidence to support a disassociation between self-reported hand preference and outcomes of hand performance assessments. This brief communication is intended to highlight the various methods used to determine hand preference, to discuss the relationship between hand preference inventories and performance measures and to present some recent findings associated with hand preference and musculoskeletal disorders.     

Blood product storage: does age really matter?

Red blood cell transfusion therapy has been used with the ultimate goal of enhancing oxygen delivery to vital organs and tissue beds, thus enhancing cellular function. Red blood cell transfusion therapy is also a long-standing practice, and since the 1950s it has only grown in utilization, especially within the United States. Recently, transfusion therapy has come under increased scrutiny with a desire to develop evidence-based therapeutic guidelines that not only decrease undue risk to the patient but also decrease the overutilization of this high-cost, low-availability product. Despite the development and implementation of these guidelines, significant complications associated with red cell therapy persist and may be related to storage of blood products. Recently, within the transfusion literature, there has been a renewed focus on red cell storage lesions and their contributions to perioperative outcomes. Several meta-analyses, and now a recently launched, multinational randomized controlled trial, have been initiated to help bring clarity to whether or not the length of product storage has any effect on patient outcomes. This review will focus on the nature of storage lesions, complications associated with storage, as well as a brief review of some of the more provocative literature surrounding this controversial topic.     

Results after laparoscopic fundoplication: does age matter?

Antireflux fundoplications are undertaken with hesitation in older patients because of presumed higher morbidity and poorer outcomes. This study was undertaken to determine if symptoms of gastroesophageal reflux disease (GERD) could be safely abrogated in a high-risk/reward popu lation of older patients. One hundred eight patients more than 70 years of age (range, 70-90 years) underwent laparoscopic Nissen fundoplications undertaken between 1992 and 2005 and were compared with 108 concurrent patients less than 60 years of age (range, 18-59 years) to determine relative outcomes. Before and after fundoplication, patients scored the severity of reflux and dysphagia on a Likert Scale (0 = minor, 10 = severe). Before fundoplication, older patients had lower reflux scores (P < 0.01), but not lower dysphagia scores or DeMeester scores. One patient (86 years old) died from myocardial infarction; otherwise, complications occurred infrequently, inconsequentially, and regardless of age. At similar durations of follow-up, reflux and dysphagia scores significantly improved (P < 0.01) for older and younger patients. After fundoplication, older patients had lower dysphagia scores (P < 0.01) and lower reflux scores (P < 0.01). At the most recent follow-up, 82 per cent of older patients rated their relief of symptoms as good or excellent. Similarly, 81 per cent of the younger patients reported good or excellent results. Ninety-one per cent of patients 70 years of age or more versus 85 per cent of patients less than 60 years would undergo laparoscopic Nissen fundoplication again, if necessary. With fundoplication, symptoms of GERD improve for older and younger patients, with less symptomatic dysphagia and reflux in older patients after fundoplication. Laparoscopic fundoplication safely ameliorates symptoms of GERD in elderly patients with symptomatic outcomes superior to those seen in younger patients.     

Gender and carotid endarterectomy: does it matter?

Objective: Multiple large series have retrospectively identified female gender as a risk factor for perioperative stroke and death after carotid endarterectomy (CEA).Methods: Data for all patients who underwent CEA at a single institution from January 1990 to December 1998 were entered into a computerized vascular registry and form the basis of this report.Results: A total of 1298 CEA procedures were performed, of which 520 (40%) were in women and 778 (60%) in men. The mean age was 69.8 ± 8.7 years for men and 71.2 ± 8.5 years for women (P < .001). Cardiac risk factors significantly varied among the two groups, with women more likely to have diabetes (42% vs 36%) and hypertension (77% vs 66%), whereas tobacco history was higher among men (85% vs 71%) (P < .05 for all). Female patients were more likely to be asymptomatic at presentation (men, 44% vs women, 51%; P = .022). Postoperative myocardial infarction occurred in eight patients (0.6%) with no differences between men (0.4%) and women (1.0%) (P = not significant). For all adverse postoperative cardiac events (myocardial infarction, congestive heart failure, or arrhythmia), the incidence was 1.9% (25 patients), again with no differences between men (1.5%) and women (2.5%) (P = not significant). There were 25 postoperative neurologic events (19 strokes, six transient ischemic attacks) among the entire cohort (1.9%), of which 16 were in men (2.1%) and nine in women (1.6%; P = not significant). The overall postoperative stroke rate was 1.5% (13 [1.7%] of 778 men; 6 [1.2%;] of 520 women; P = not significant). Total operative mortality was 0.3% (3 [0.4%] of 778 men; 1 [0.2%] of 778 women; P = not significant). Late recurrent stenosis requiring operation developed in 14 patients (1.1%) during follow-up (6 [0.8%] of 778 men; 8 [1.5%] of 520 women; P = .19).Conclusions: Although there is significant variability in cardiac risk factors and presentation, female gender is not a risk factor for stroke, death, or cardiac morbidity after CEA. Women are not at higher risk for reoperation for recurrent stenosis.     

Fall from heights: does height really matter?

Introduction

Fall from heights is high energy injuries and constitutes a fraction of all fall-related trauma evaluations while bearing an increase in morbidity and mortality. We hypothesize that despite advancements in trauma care, the overall survivability has not improved in this subset of trauma patients.

Methods

All adult trauma patients treated after sustaining a fall from heights during a 40-month period were retrospectively reviewed. Admission demographics, clinical data, fall height (ft), injury patterns, ISS, GCS, length of stay, and mortality were reviewed.

Results

116 patients sustained a fall from heights, 90.4% accidental. A mean age of 37± 14.7 years, 86% male, and a fall height of 19 ± 10 ft were encountered. Admission GCS was 13 ± 2 with ISS 10 ± 11. Overall LOS was 6.6 ± 14.9 days and an ICU LOS of 2.8 ± 8.9 days. Falls ≥ 25 ft.(16%) had lower GCS 10.4 ± 5.8, increased ISS 22.6 ± 13.8, a fall height 37.9 ± 13.1 ft and associated increased mortality (p < 0.001). Mortality was 5.2%, a mean distance fallen of 39 ± 22 ft. and an ISS of 31.5 ±16.5. Brain injury was the leading cause of death, 50% with open skull fractures.

Conclusion

Level of height fallen is a good predictor of overall outcome and survival. Despite advances in trauma care, death rates remain unchanged. Safety awareness and injury prevention programs are needed to reduce the risk of high-level falls.

     

Tissue-engineered vascular grafts: does cell seeding matter?

Purpose

Use of tissue-engineered vascular grafts (TEVGs) in the repair of congenital heart defects provides growth and remodeling potential. Little is known about the mechanisms involved in neovessel formation. We sought to define the role of seeded monocytes derived from bone marrow mononuclear cells (BM-MNCs) on neovessel formation.

Methods

Small diameter biodegradable tubular scaffolds were constructed. Scaffolds were seeded with the entire population of BM-MNC (n = 15), BM-MNC excluding monocytes (n = 15), or only monocytes (n = 15) and implanted as infrarenal inferior vena cava (IVC) interposition grafts into severe combined immunodeficiency/bg mice. Grafts were evaluated at 1 week, 10 weeks, or 6 months via ultrasonography and microcomputed tomography, as well as by histologic and immunohistochemical techniques.

Results

All grafts remained patent without stenosis or aneurysm formation. Neovessels contained a luminal endothelial lining surrounded by concentric smooth muscle cell layer and collagen similar to that seen in the native mouse IVC. Graft diameters differed significantly between those scaffolds seeded with only monocytes (1.022 ± 0.155 mm) and those seeded without monocytes (0.771 ± 0.121 mm; P = .021) at 6 months.

Conclusions

Monocytes may play a role in maintaining graft patency. Incorporation of such findings into the development of second-generation TEVGs will promote graft patency and success.     

Contralateral papillary thyroid cancer: does size matter?

Background

The optimal extent of thyroidectomy for papillary thyroid cancer (PTC) <1 cm is controversial. Our aim was to identify the rate and factors predictive of contralateral PTC in these patients.

Methods

We examined 228 patients with PTC who underwent either completion or total thyroidectomy and analyzed the predictive value of tumor size, histology, margin status, capsular invasion, extrathyroid extension, multifocality, and node metastases.

Results

We observed no differences in the rate of contralateral disease in patients with primary PTC ≥1 cm compared with those having disease <1 cm, 30% versus 24%, respectively (P = .43). Multifocality was the only factor predictive of contralateral PTC in patients with tumors <1 cm (P = .02). Patients with tumors <.5 cm also had a comparable rate of contralateral disease (27%).

Conclusions

The presence of contralateral PTC appears to be unrelated to the size of the primary tumor. Furthermore, in patients with PTC <1 cm, multifocality is a risk factor for PTC in the contralateral lobe.