Laparoscopic or open cholecystectomy in patients with sickle cell disease: which approach is superior?

OBJECTIVE: To compare laparoscopic with open cholecystectomy in patients with sickle cell disease. DESIGN: Retrospective clinical study. SETTING: University hospital, Greece. SUBJECTS: 41 patients (22 men and 19 women) with sickle cell disease had laparoscopic cholecystectomy between September 1991 and June 1998. Each patient was matched for age, sex, year of operation, and number of preoperative transfusions with control patients with sickle cell disease who had open cholecystectomy. MAIN OUTCOME MEASURES: Duration of operation, postoperative stay in hospital, incidence of complications, and conversion to open operation. RESULTS: The mean operation time was 81.4 min (range 55-125) for open cholecystectomy and 64.2 min (range 45-90) for laparoscopic cholecystectomy (p < 0.01). Complications occurred in 5% (2/41) of the patients in the laparoscopic group and in 20% (8/41) of the patients in the open group (p = 0.04). The mean length of stay in hospital was 5.6 days (range 3-9) in the open group and 2.7 days (range 2-5) in the laparoscopic group (p < 0.01). Conversion to open operation was necessary in 2 (5%) patients. CONCLUSIONS: Laparoscopic cholecystectomy resulted in a shorter hospital stay with fewer postoperative complications than open operation in patients with sickle cell disease and may be the procedure of choice in the treatment of cholelithiasis in such patients.     

Can patients treat themselves with a small novel light based hair removal system?

BACKGROUND AND OBJECTIVES: This study was designed to evaluate the safety and effectiveness of a small, low energy light based system for hair removal, when used by non-healthcare professionals ("patients") for self treatment in home-like environment following instructions and guidance provided by a physician. STUDY DESIGN/MATERIALS AND METHODS: A total of 73 patients between the ages of 19 and 54 years with skin types I through IV were enrolled in the study out of which 67 completed the study. Two treatment sites were chosen from among the arms, axilla, legs, bikini, back, belly, chest or face. The hair on the sites was trimmed and photographed. Each patient performed two self-treatments, using the hair removal device on their designated body sites, under the Investigator's direction. The first self-treatment was performed at the Investigator's office by the patient while the second self-treatment was performed 4 weeks later at a hotel room, simulating the home environment. Follow-up visits to evaluate the safety and efficacy of the treatments were performed 2 and 12 weeks following the last self-treatment. RESULTS: The mean hair reduction was 33.6%, 4 weeks after the first self-treatment, 44.3%, 2 weeks following the last self-treatment, and 32.3%, 12 weeks following the last treatment. All the noted side effects were mild and transient. Transient erythema was noted in 47.5% of the patients. Other transient side effects reported include edema (5%), hyperpigmentation (4.75%), crusting (2.35%), hypopigmentation (1.55%), and blistering (1.4%). All noted side effects were resolved by the 12-week follow-up visit. CONCLUSIONS: With adequate training and instruction, patients may administer self-treatments for hair removal with this small light based unit in a safe and effective manner.     

Can propofol precipitate pancreatitis in patients with Cushing's syndrome?

We encountered two cases of acute pancreatitis in patients with Cushing's disease following transnasal transsphenoidal hypophysectomy. In both cases propofol was used in bolus doses, and is thought to be the probable factor for its development. Since elevated cortisol levels in Cushing's disease poses a threat for pancreatitis, there is a possibility that patients with Cushing's disease might be more prone to acute pancreatitis following propofol administration. Anaesthesiologists and physicians dealing with the management of Cushing's disease need to be aware of this possibility.     

Asymptomatic cholelithiasis in children with sickle cell disease: early or delayed cholecystectomy?

SUMMARY BACKGROUND DATA: Our study aimed to evaluate the role of elective laparoscopic cholecystectomy (LC) in children with sickle cell disease (SCD) and asymptomatic cholelithiasis and, furthermore, to determine whether the outcome is related to the operation timing. METHODS: The records of 30 children with SCD diagnosed with cholelithiasis from June 1995 to September 2005 were retraspectively reviewed. All 30 children were asymptomatic at the time of the first visit, and an elective LC was proposed to all of them. The operation was accepted in the period of study by 16 children and refused by 14. During medical observation, 10 of the 14 children who refused surgery were admitted for severe biliary colics. Acute cholecystitis was diagnosed by abdominal ultrasound in 3 cases and in 1 case choledocholithiasis, ultrasonographically suspected, was confirmed by magnetic resonance cholangiopancreatography (MRCP) and treated during endoscopic retrograde cholangiopancreatography (ERCP). All children, emergency admitted, underwent LC after the onset of symptoms. The patients were divided up into 2 groups (A: asymptomatic; B: symptomatic) depending on clinical presentation and operation timing and the respective outcomes were compared. RESULTS: Elective LC in asymptomatic children (group A) is safe with no major complications reported. During medical observation in children who refused elective surgery (group B), 6 biliary colics, 3 acute cholecystitis, and 1 choledocholithiasis were observed. Three sickle cell crises occurred in symptomatic children during biliary colics. The correlation between cholecystectomy performed in asymptomatic children (group A) and cholecystectomy performed in symptomatic children (group B) showed significant differences in the outcome. Morbidity rate and postoperative stay increased when children with SCD underwent emergency LC. CONCLUSIONS: Elective LC should be the gold standard in children with SCD and asymptomatic cholelithiasis to prevent the potential complications of biliary colics, acute cholecystitis, and choledocholithiasis, which lead to major risks, discomfort, and longer hospital stay.     

Can we do better with postoperative pain management?

BACKGROUND: In the last decade, there has been heightened awareness that pain management needs to be a priority for all health care settings and clinicians. The article will overview practice guidelines and new technology, and assess their impact on pain relief in inpatient and outpatient surgeries from a patient's perspective. METHODS: Literature was retrieved by searches from 1996 to 2000 Medline and CINAHL (nursing database), using keywords "postoperative pain," "postsurgical pain," "patient outcomes," "pain outcomes," "survey," "questionnaire," and "practice guidelines." RESULTS: Overall, current practice standards have had minimal impact on decreasing patients' reports of pain. The incidence of moderate to severe pain with cardiac, abdominal, and orthopedic inpatient procedures has been reported as high as 25% to 50%, and incidence of moderate pain after ambulatory procedures is 25% or higher. CONCLUSIONS: Despite the advances, the incidence of pain remains high. Yet the future is promising, with new standards from the Joint Commission on Accreditation of Health care Organizations paving the way for reduction of institutional barriers and improved implementation of guidelines.     

Long-term outcome from a study on the prevention of postoperative recurrence in patients with renal cell carcinoma: could PBL be a predictor of postoperative recurrence in patients postoperatively treated with IFN-gamma?

This study examined the outcome of postoperative recurrence therapy on renal cell carcinoma (RCC) prevention involving treatment with single doses of interferon-gamma (IFN-gamma). From 1990-2000, 37 patients with no distant metastasis at the time they underwent a nephrectomy were enrolled in this investigation. Subcutaneous IFN-gamma was administered once a week. Total and differential white blood cells were counted before the pre-administration of IFN-gamma and then monthly thereafter for all patients. Blood lymphocyte subsets were analyzed phenotypically by direct immunofluorescence. Disease-free survival rates (DFSR) at 5 and 10 years were 81.7% and 75.9%, respectively. To clarify the effects of preoperative peripheral blood lymphocyte (PBL) and NK activity on DFSR, we categorized the patients into two groups according to the median number of PBL before the administration of IFN-gamma. Except for CD11b, PBL level had no effect on DFSR. Multiple logistic regression analysis showed that CD11b levels greater than 16.5% were associated with 25.35 odds ratio increase in the risk of postoperative recurrence. A multivariate analysis found that CD11b may be an independent factor for postoperative recurrence. In terms of preventing postoperative recurrence, our results showed that an elevated CD11b level may indicate patients who can benefit from further combination therapy.     

Can we identify risk factors for postoperative delirium in cardiac coronary patients? Our experience

Introduction: Delirium is a temporary mental disorder that frequently occurs among elderly hospitalized patients. Patients who undergo cardiac operations have an increased risk of postoperative delirium, which is associated with higher mortality and morbidity rates, a prolonged hospital stay, and reduced cognitive and functional recovery.Patients and Methods: In our prospective study, we included 370 consecutive adult patients who underwent on-pump coronary artery surgery between January 1, 2011, and July 1, 2011. We selected 21 potential risk factors and divided them into preoperative, intraoperative, and postoperative groups. Delirium was diagnosed with the Confusion Assessment Method.Results: Postoperative delirium was diagnosed in 74 patients (20%). Four predictive factors were associated with postoperative delirium: diabetes mellitus, cerebrovascular disease, peripheral vascular disease, and prolonged intubation (P < .05).Conclusion: Three of the four predictive factors significantly associated with delirium are preoperative. They are relatively easy to measure and can be used to identify patients at higher risk. Fast extubation of these patients and preventive interventions can be taken to prevent negative consequences of this postoperative complication.     

Is postoperative calcium channel blocker therapy needed in patients with radial artery grafts?

BACKGROUND: Chronic calcium channel blocker therapy has traditionally been considered necessary in patients carrying a radial artery graft, even in the absence of objective data to support it. This report was conceived to evaluate the angiographic and clinical effects of calcium channel blocker therapy during the first postoperative year. PATIENTS AND RESULTS: A total of 100 consecutive patients who received a radial artery graft at our institution were randomly assigned to receive (n = 53) or not receive (n = 47) calcium channel blocker therapy with oral diltiazem 120 mg/daily started in the early postoperative period. At 1-year follow-up, all patients were reassessed clinically and by Tl 201 myocardial scintigraphy, and 83 of them underwent control angiography. In 12 cases we also evaluated the response of the radial artery to the endovascular infusion of serotonin. No difference in terms of clinical outcome, scintigraphic results, and patency rate was found between patients who received or did not receive calcium channel blocker therapy. Endovascular serotonin infusion evoked an evident spastic reaction of radial artery grafts, not attenuated by calcium channel blocker therapy. CONCLUSION: Calcium channel blocker therapy started immediately after surgery and continued for the first postoperative year does not affect radial artery graft patency and clinical and scintigraphic outcomes. On the basis of these data, the prophylactic use of calcium channel blocker therapy in patients with radial artery grafts seems unsubstantiated.     

Back pain in patients with degenerative spine disease and intradural spinal tumor: what to treat? when to treat?

Background

Back pain is common in industrialized countries and one of the most frequent causes of work incapacity. Successful treatment is, therefore, not only important for improving the symptoms and the quality of life of these patients but also for socioeconomic reasons. Back pain is frequently caused by degenerative spine disease. Intradural spinal tumors are rare with an annual incidence of 2–4/1,00,000 and are mostly associated with neurological deficits and radicular and nocturnal pain. Back pain is not commonly described as a concomitant symptom, such that in patients with both a tumor and degenerative spine disease, any back pain is typically attributed to the degeneration rather than the tumor.

Objective

The aim of the present retrospective investigation was to study and analyze the impact of microsurgery on back/neck pain in patients with intradural spinal tumor in the presence of degenerative spinal disease in adjacent spinal segments.

Methods

Fifty-eight consecutive patients underwent microsurgical, intradural tumor surgery using a standardized protocol assisted by multimodal intraoperative neuromonitoring. Clinical symptoms, complications and surgery characteristics were documented. Standardized questionnaires were used to measure outcome from the surgeon’s and the patient’s perspectives (Spine Tango Registry and Core Outcome Measures Index). Follow-up included clinical and neuroradiological examinations 6 weeks, 3 months and 1 year postoperatively.

Results

Back/neck pain as a leading symptom and coexisting degenerative spine disease was present in 27/58 (47 %) of the tumor patients, and these comprised to group under study. Patients underwent tumor surgery only, without addressing the degenerative spinal disease. Remission rate after tumor removal was 85 %. There were no major surgical complications. Back/neck pain as the leading symptom was eradicated in 67 % of patients. There were 7 % of patients who required further invasive therapy for their degenerative spinal disease.

Conclusions

Intradural spinal tumor surgery improves back/neck pain in patients with coexisting severe degenerative spinal disease. Intradural spinal tumors seem to be the only cause of back/neck pain more often than appreciated. In these patients suffering from both pathologies, there is a higher risk of surgical overtreatment than undertreatment. Therefore, elaborate clinical and radiological examinations should be performed preoperatively and the indication for stabilization/fusion should be discussed carefully in patients foreseen for first time intradural tumor surgery.     

Can fecal continence be predicted in patients born with anorectal malformations?

PurposeThe purpose of this study was to identify factors associated with attaining fecal continence in children with anorectal malformations (ARM).MethodsWe performed a multi-institutional cohort study of children born with ARM in 2007–2011 who had spinal and sacral imaging. Questions from the Baylor Social Continence Scale were used to assess fecal continence at the age of ≥ 4 years. Factors present at birth that predicted continence were identified using multivariable logistic regression.ResultsAmong 144 ARM patients with a median age of 7 years (IQR 6–8), 58 (40%) were continent. The rate of fecal continence varied by ARM subtype (p = 0.002) with the highest rate of continence in patients with perineal fistula (60%). Spinal anomalies and the lateral sacral ratio were not associated with continence. On multivariable analysis, patients with less severe ARM subtypes (perineal fistula, recto-bulbar fistula, recto-vestibular fistula, no fistula, rectal stenosis) were more likely to be continent (OR = 7.4, p = 0.001).ConclusionType of ARM was the only factor that predicted fecal continence in children with ARM. The high degree of incontinence, even in the least severe subtypes, highlights that predicting fecal continence is difficult at birth and supports the need for long-term follow-up and bowel management programs for children with ARM.Type of StudyProspective Cohort Study.Level of EvidenceII.     

Is it safe to discharge geriatric trauma patients with anemia?

Introduction

The consequences of discharging anemic geriatric trauma patients are not well studied. We hypothesize that anemia at discharge is associated with adverse outcomes.

Can subfoveal choroidal thickness replace subjective tests in patients using tadalafil to treat erectile dysfunction?

We aimed to determine the effect on choroidal thickness of daily 5 mg tadalafil use in patients with erectile dysfunction (ED) and to evaluate agreement between short form of International Index of Erectile Function (IIEF 1–5, 15) scores and choroidal thickness during follow-up. Enhanced depth imaging spectral domain–optical coherence tomography (EDI-OCT) was used to measure full choroidal thickness in the subfoveal area, choroidal thickness (CT) and small-choroidal-vessel-layer (SCVL) thickness. Thirty of the 45 patients included complete their follow-ups and exhibited medication continuity. Patients were divided into two groups, five (16.7%) with ED at any level at third-month follow-up, and 25 (83.3%) with no ED, and subgroup analysis was then performed. Median changes in SCVL thickness at first- and sixth-month follow-ups were 20.5 µm versus 9.0 μm (p = .001) and 23.5 µm versus 12.5 µm (p = .005) in patients without and with ED respectively. The SCVL thickness increased by 20 μm compared with the baseline level, indicating an improvement in the patient's complaints of erectile dysfunction. The level of increase in SCVL thickness can be a useful and objective guide to clinicians if they cannot be present when the IIEF questionnaire is administered.     

Hemodilution and anemia in patients with cardiac disease: what is the safe limit?

PURPOSE OF THE REVIEW: Anemia is associated with increased perioperative morbidity and mortality, especially in patients with cardiovascular disease. Although blood transfusions are commonly used in these patients, there is little evidence that such an approach improved patients' clinical outcome. RECENT FINDINGS: From an experimental point of view, tolerance to acute anemia is significantly reduced in animals with externally applied coronary artery stenosis. In rats subjected to transient coronary occlusion, however, moderate isovolemic hemodilution attenuated myocardial damage and improved survival. Tolerance to severe anemia could also be improved by hyperoxic ventilation and maintenance of adequate coronary perfusion pressure. From the clinical perspective, tolerance to anemia in patients with cardiovascular disease closely depends on myocardial oxygen demand, in particular on the level of heart rate. A reduction in heart rate as observed in anesthetized patients undergoing moderate hemodilution may confer some cardioprotection. SUMMARY: The absolute lowest threshold for anemia in patients with cardiac disease cannot be established. Further studies are needed to develop evidence-based transfusion guidelines for these patients. Rather than primarily focusing on transfusion, physicians should first administer therapies that have been shown to improve outcome. In the setting of coronary artery disease, control of heart rate appears of paramount importance.