Laparoscopic pyloromyotomy: comparing the arthrotomy knife to the Bovie blade

Background

Laparoscopic pyloromyotomy was performed at our institution using an arthrotomy knife until it became unavailable in 2010. Thus, we adapted the use of the blunt Bovie tip, which can be used with or without electrocautery to perform the myotomy. This study compared the outcomes between using the arthrotomy knife versus the Bovie blade in laparoscopic pyloromyotomies.

Materials and methods

Retrospective review was performed on all laparoscopic pyloromyotomy patients from October 2007 to September 2012. Arthrotomy knife pyloromyotomy patients were compared with those performed with the Bovie blade. Patient demographics, diagnostic measurements, electrolyte levels, length of stay, operative time, and complications were compared.

Results

A total of 381 patients were included, with 191 in the arthrotomy group and 190 in the Bovie blade group. No significant differences existed between groups in age, weight, gender, pyloric dimensions, electrolyte levels, or length of stay. Mean operative times were 15.8 ± 5.6 min with knife and 16.4 ± 5.3 min for Bovie blade (P = 0.24). In the arthrotomy knife group, there was one incomplete pyloromyotomy and one omental herniation. There was one wound infection in each group. Readmission rate was greater in the arthrotomy knife group (5.7%) versus the Bovie blade group (3.1%).

Conclusions

The Bovie blade appears to offer no objective disadvantages compared with the arthrotomy knife when performing laparoscopic pyloromyotomy.     

Do laparoscopic skills transfer to robotic surgery?

Background

Identifying the set of skills that can transfer from laparoscopic to robotic surgery is an important consideration in designing optimal training curricula. We tested the degree to which laparoscopic skills transfer to a robotic platform.

Methods

Fourteen medical students and 14 surgery residents with no previous robotic but varying degrees of laparoscopic experience were studied. Three fundamentals of laparoscopic surgery tasks were used on the laparoscopic box trainer and then the da Vinci robot: peg transfer (PT), circle cutting (CC), and intracorporeal suturing (IS). A questionnaire was administered for assessing subjects' comfort level with each task.

Results

Standard fundamentals of laparoscopic surgery scoring metric were used and higher scores indicate a superior performance. For the group, PT and CC scores were similar between robotic and laparoscopic modalities (90 versus 90 and 52 versus 47; P > 0.05). However, for the advanced IS task, robotic-IS scores were significantly higher than laparoscopic-IS (80 versus 53; P < 0.001). Subgroup analysis of senior residents revealed a lower robotic-PT score when compared with laparoscopic-PT (92 versus 105; P < 0.05). Scores for CC and IS were similar in this subgroup (64 ± 9 versus 69 ± 15 and 95 ± 3 versus 92 ± 10; P > 0.05). The robot was favored over laparoscopy for all drills (PT, 66.7%; CC, 88.9%; IS, 94.4%).

Conclusions

For simple tasks, participants with preexisting skills perform worse with the robot. However, with increasing task difficulty, robotic performance is equal or better than laparoscopy. Laparoscopic skills appear to readily transfer to a robotic platform, and difficult tasks such as IS are actually enhanced, even in subjects naive to the technology.     

Comparison of surgical outcomes between papillary thyroid cancer patients treated with the Harmonic ACE scalpel and LigaSure Precise instrument during conventional thyroidectomy: a single-blind prospective randomized controlled trial

Background

The aim of this study was to evaluate the safety and efficacy of thyroidectomy using the Harmonic ACE scalpel (HS) or the LigaSure Precise (LS) instrument in conventional thyroidectomy.

Materials and methods

A prospective, randomized controlled trial was performed. Between August 2011 and June 2012, 832 patients who required thyroidectomy for papillary thyroid cancer were randomized into groups treated with either the HS or the LS instrument. Operative time and surgical morbidities were analyzed.

Results

A total of 320 patients (HS group, N = 164; LS instrument group, N = 156) were randomized for analysis according to the intention-to-treat principle. There were no statistically significant differences in the operative times (HS group versus LS instrument group: 71.93 ± 18.26 versus 75.15 ± 20.13; P = 0.423), postoperative transient hypoparathyroidism (13.4% versus 14.1%; P = 0.858), and permanent recurrent laryngeal nerve injuries between the two groups.

Conclusions

In this study, both hemostatic devices were safe and effective in terms of postoperative results and complications without any differences.     

Novel functional role of heat shock protein 90 in protein kinase C-mediated ischemic postconditioning

Background

Previous studies have shown that heat shock protein 90 (HSP90) plays a vital role in ischemic preconditioning. The present study was designed to explore whether HSP90 might be responsible for cardioprotection in ischemic postconditioning (PostC).

Materials and methods

Rat hearts underwent 30 min of regional ischemia and 2 h of reperfusion in situ, and PostC was effected with three cycles of 30-s reperfusion and 30-s coronary artery occlusion at the end of ischemia. Ninety rats were randomized into five groups: sham; ischemia–reperfusion (I/R); PostC; 1 mg/kg HSP90 inhibitor geldanamycin (GA) plus PostC (PostC + GA1); and 5 mg/kg GA plus PostC (PostC + GA5). The GA was administered 10 min before reperfusion.

Results

Compared with the I/R group, the PostC group exhibited lower infarct size (46.7 ± 3.0% versus 27.4 ± 4.0%, respectively), release of lactate dehydrogenase and creatine kinase-MB (2252.6 ± 350.8 versus 1713.7 ± 202.4 IU/L, 2804.3 ± 315.7 versus 1846.2 ± 238.0 IU/L, respectively), cardiomyocyte apoptosis (48.4 ± 5.6% versus 27.6 ± 3.8%, respectively), and mitochondrial damage. These beneficial effects were accompanied by an increase in mitochondrial Bcl-2 levels and a decrease in Bax levels. In addition, mitochondrial protein kinase Cepsilon (PKCepsilon) was relatively low in the I/R group but significantly higher in the PostC group, whereas cytosolic PKCepsilon was relatively high in the I/R group but significantly lower in the PostC group, suggesting the translocation of PKCepsilon from cytosol to mitochondria during PostC. However, blocking HSP90 function with GA inhibited the protection of PostC and PKCepsilon mitochondrial translocation.

Conclusions

HSP90 is critical in PostC-induced cardioprotection, and its activity might be linked to mitochondrial targeting of PKCepsilon, the activation of which results in upregulation of its target gene, Bcl-2, and the inhibition of proapoptotic Bax in mitochondria.     

The effects of tramadol on postoperative nausea, vomiting and headache after ENT surgery. A placebo-controlled comparison with equipotent doses of nalbuphine and pethidine

Background: Opioids given as adjuncts to balanced inhalational anaesthesia augment postoperative nausea and vomiting (PONV). Tramadol, equipotent to pethidine, does not depress respiration, but can cause an increase in blood pressure and headache via its monoaminergic actions. Nalbuphine, ten times as potent as pethidine, has a ceiling respiratory depressant and ceiling analgesic effect at >0.3 mg · kg^?1. We compared the effects of equipotent doses of tramadol and nalbuphine (3.0 and 0.3 mg · kg^?1, respectively) given as analgesic with induction of anaesthesia on emesis during recovery from anaesthesia and on PONV and headache until 24 h after ENT surgery, using saline (0.2 ml · kg^?1) and an equipotent dose of pethidine (1.5 mg · kg^?1) as controls. Method: The study population (N=281) comprised 4 comparable subgroubs (N=69 to 71 each). Anaesthetic medications were standardised. Emesis during recovery from anaesthesia and nausea, vomiting, retching, headache and administrations of antiemetic and analgesics until 24 h after surgery were recorded. Results: Emesis and antiemetic requirements during recovery from anaesthesia were similar and infrequent in each group, as were the incidences of nausea alone (3 to 5%), vomiting alone (17 to 31%), and nausea with vomiting (10 to 22%) during the first 24 h after surgery. However, any complaint of PONV was least frequent in the saline and pethidine groups (32% and 37%, respectively) and most frequent in the tramadol and nalbuphine groups (49% and 52%, respectively; P<0.05 versus saline, both comparisons; P=NS versus pethidine, both comparisons). The times to onset and severity of PONV were similar in each group, but patients given nalbuphine most frequently (P<0.025) needed rescue antiemetic to treat PONV. Headache occurred with similar frequency in each group. Conclusion: It is concluded that tramadol, nalbuphine and pethidine have similar emetic effect in the doses and manner used, and that tramadol does not increase the incidence of postoperative headache when used as peroperative analgesic.     

Blowhole colostomy for the urgent management of distal large bowel obstruction

Background

Complete obstruction of the distal colon or rectum often presents as a surgical emergency. This study evaluated the efficacy of blowhole colostomy versus transverse loop colostomy for the emergent management of distal large intestinal obstruction.

Methods

Retrospective chart review of all colostomy procedures (CPT 44320) performed for complete distal large bowel obstruction during the past 6 y in a university hospital practice was undertaken. Blowhole was compared with loop colostomy with a primary endpoint of successful colonic decompression.

Results

One hundred forty-one patients underwent colostomy creation during the study period. Of these, 61 were completed for acute obstruction of the distal colon or rectum (19 blowhole versus 42 loop colostomy). No differences between study groups were seen in age, gender, body mass index, malnutrition, American Society of Anesthesiology class, time to liquid or regular diet, 30-d or inhospital mortality, or rates of complications. Patients undergoing blowhole colostomy had significantly higher cecal diameters at diagnosis (9.14 versus 7.31 cm, P = 0.0035). Operative time was shorter in blowhole procedures (43 versus 51 min, P = 0.017). Postoperative length of stay was significantly shorter for blowhole colostomy (6 versus 8 d, P = 0.014). The primary endpoint of successful colonic decompression was met in all colostomy patients.

Conclusions

Diverting blowhole colostomy is a safe, quick, and effective procedure for the urgent management of distal colonic obstruction associated with obstipation and massive distention.     

Impact of a blood conservation program on 30-day morbidity and mortality: a cohort study

Background

There are little published data on outcomes of blood conservation (BC) patients after noncardiac surgery. The objective of this study was to compare the surgical outcomes of patients enrolled in our BC program with that of the general population of surgical patients.

Methods

BC patients at our institution undergoing various surgical procedures were identified from the 2007–2009 National Surgical Quality Improvement Program database and compared with a cohort of conventional care (CC) patients matched by age, gender, and surgical procedure. Univariate and multiple logistic regression analyses were performed to evaluate 30-d postoperative outcomes.

Results

One hundred twenty BC patients were compared with 238 CC patients. The two groups were similar for all preoperative variables except smoking, which was lower in the BC group. On univariate analysis, BC patients had similar mean operating time (148 versus 155 min; P = 0.5), length of stay (5.9 versus 5.5 d; P = 0.7), and rate of return to the operating room (7.5% versus 5.5%; P = 0.4) compared with CC patients. BC and CC patients had similar 30-d morbidity (18% versus 14%; P = 0.3) and mortality rates (1.6% versus 1.3%; P = 1.0), respectively. On multivariable analysis, enrollment in the BC program had no impact on postoperative 30-d morbidity (odds ratio, 1.78; 95% confidence interval, 0.71–4.47) or 30-d mortality (unadjusted odds ratio, 1.33; 95% confidence interval, 0.22–8.05).

Conclusions

Short-term postoperative outcomes in BC patients are similar to the general population, and these patients should not be denied surgical treatment based on their unwillingness to receive blood products.     

Ultrapure alginate anti-adhesion gel does not impair colon anastomotic strength

Background

Ultrapure alginate gel is promising in terms of adhesion prevention. Because anti-adhesive barriers have been shown to disturb healing of bowel anastomoses, the effect of ultrapure alginate gel on the repair of colon anastomoses was studied.

Materials and methods

In 102 male Wistar rats, a 0.5-cm segment was resected from the descending colon and continuity was restored by an inverted single-layer end-to-end anastomosis. Animals were randomized into a control, an alginate gel, and a sodium hyaluronate carboxymethyl cellulose film group, each n = 34. Half of each group was sacrificed at day 3 and 7 postoperatively. Anastomotic strength was assessed by measuring both bursting pressure and breaking strength. Hydroxyproline content was measured and histologic analysis was performed. The incidence of adhesion and abscess formation was scored at sacrifice.

Results

No difference in either anastomotic-bursting pressure or breaking strength was found between experimental groups and the controls at any time point. Both the incidence of adhesion formation (35% versus 71%, P = 0.007) and the adhesion score (0.38 versus 0.79, P = 0.009) were significantly lower in the alginate gel group than in the controls. The abscess rate was higher (46% versus 18%, P = 0.030) in the hyaluronate carboxymethyl cellulose group than in the controls and unchanged in the alginate gel group.

Conclusions

While reducing adhesion formation, ultrapure alginate gel does not interfere with the development of colonic anastomotic strength during the crucial early healing period.     

Delayed remote preconditioning induces cardioprotection: role of heme oxygenase-1

Background

The role of heme oxygenase-1 (HO-1) in the cardioprotection induced by delayed remote ischemic preconditioning (DRIPC) has not been investigated. Therefore, this study was designed to investigate whether HO-1 is involved in DRIPC-mediated cardioprotection in an isolated perfused rat heart model.

Materials and methods

Isolated rat hearts were subjected to 30 min ischemia followed by 60 min reperfusion. DRIPC (four cycles 5-min occlusion and 5-min reflow at the unilateral hind limb once per day for 1, 2, or 3 d before heart isolation, abbreviated as D1RIPC, D2RIPC, or D3RIPC respectively). Infarct size, myocardial troponin levels, and heart function were measured. The protein and messenger RNA levels of HO-1 were determined.

Results

DRIPC facilitated postischemic cardiac functional recovery and decreased cardiac enzyme release. The infarct size-limiting effect of DRIPC was more pronounced in the D3RIPC group (10.22 ± 2.57%) than the D1RIPC group (22.34 ± 4.02%, P < 0.001) or the D2RIPC group (14.60 ± 3.13%, P = 0.034). These effects in the D1RIPC group could be blocked by Zinc Protoporphyrin IX (ZnPP) (an HO-1 specific inhibitor). DRIPC-mediated cardioprotection was associated with enhanced HO-1 protein expression (D1RIPC, 0.11 ± 0.03; versus 0.15 ± 0.06 in the D2RIPC group, P = 0.06; versus 0.20 ± 0.04 in the D3RIPC group, P = 0.04) and messenger RNA levels of HO-1 expression.

Conclusions

Our findings suggest that HO-1 is involved in the cardioprotection induced by DRIPC, and that increase in the number of preconditioning stimuli may enhance cardioprotective effects accompanied with increased HO-1 level.     

Topic usage of kaolin-impregnated gauze as a hemostatic in tonsillectomy

Background

The main postoperative complications after tonsillectomy are due to bleeding, and effective hemostasis may lead to a reduction of overall postoperative morbidity. This study was undertaken to determine the efficacy and safety of a novel kaolin-based hemostatic dressing in tonsillectomy.

Methods

A pilot, single-blind, open label study was performed in patients aged 3–20 y with history of chronic or hypertrophic tonsillitis. Cold dissection tonsillectomy (CDT) + ligature was performed by the same surgeon. Hemostasis on each tonsillar fossa was achieved using kaolin-impregnated gauze (KG; study group) or standard surgical cotton gauze (CG; control). Time to complete hemostasis, operative time, intraoperative blood loss, pain score, analgesic use, and return to normal diet and activity were recorded for all children.

Results

A total of 230 patients with a mean age of 8.0 y (138 in the study group and 92 in the control group) were included in the study. Both operative time and intraoperative blood loss were significantly reduced in the KG group (P < 0.0001) versus the CG group. At 5 min, 84.8% patients using the KG successfully achieved complete hemostasis versus 34.8% in the CG group where standard gauze controlled bleeding only partially. Results show significantly less pain for the KG group at 6- and 12-h postoperative when compared with the CG group (P < 0.0001). Also, the KG group required less analgesic medications, returned to normal diet and normal activities faster than the CG group (P < 0.01).

Conclusions

Preliminary findings show that the KG is effective and safe in managing surgical bleeding after tonsillectomy. In addition to rapid bleeding control, the dressing causes minimal inflammation and pain and allows patients to quickly return to normal activities. This novel dressing is a promising tool for ear, nose and throat surgical hemostasis.     

The effects of arterial pressure during normothermic kidney perfusion

Background

Ex vivo normothermic perfusion (EVNP) can reverse some of the detrimental effects of ischemic injury. However, in kidneys with warm and cold ischemic injury the optimal perfusion pressure remains undetermined. The aim of this study was to evaluate the effects of two different arterial pressures during EVNP.

Methods

Porcine kidneys underwent static cold storage for 23 h followed by 1 h of EVNP using leukocyte depleted blood at a mean arterial pressure of either 55 or 75 mm Hg. After this, kidneys were reperfused for 3 h to assess renal function and injury. This was compared with a control group that underwent 24 h cold storage.

Results

During EVNP, kidneys perfused at 75 mm Hg had a higher renal blood flow, increased oxygen consumption (median 59.9 mL/min/g (range 30.1–78.6] versus 31.8 [8.2–53.8] mL/min/g; P = 0.026), and produced more urine (P = 0.002) than kidneys perfused at 55 mm Hg. During ex vivo reperfusion, renal blood flow was significantly higher in the 75 mm Hg and 55 mm Hg groups compared with the control (area under the curve median 75 mm Hg 462 [228–745], 55 mm Hg 454 [254–923] versus control 262 [215–442] mL/min/100g.h; P = 0.040). There was a significant loss of renal function and increase in tubular injury in the 55 mm Hg group kidneys (P = 0.001, 0.007). Levels of endothelin 1 were significantly reduced in the 75 mm Hg group (P = 0.026).

Conclusions

A mean arterial pressure of 75 mm Hg during EVNP resulted in less tubular damage and less endothelial injury during ex vivo reperfusion compared with kidneys perfused at 55 mm Hg.     

The effects of propofol and dexmedetomidine infusion on fluid responsiveness in critically ill patients

Background

We studied the effects of propofol or dexmedetomidine on preload dependency and fluid responsiveness in critically ill patients.

Methods

In the study, we included 91 patients with acute circulatory failure (70 ± 15 y) who received propofol (n = 45 patients, PROP group) or dexmedetomidine (n = 46 patients, DEX group). An initial passive leg-raising (PLR 1) test was performed in all patients to evaluate preload dependency at baseline. Propofol and dexmedetomidine were infused and titrated according to the Richmond Agitation Sedation Scale; the results ranged from −2 to −1, and the bispectral index values ranged from 60–75. A second PLR test (PLR 2) was performed before administration of a 250-mL normal saline fluid challenge over a 5-min period. We obtained central venous pressure and cardiac index (CI) measurements before and after the two PLR tests and volume expansion. An increase of ≥10% in CI during PLR was considered to be a positive test finding that was indicative of preload dependency, whereas an increase of <10% in CI during PLR was considered to be a negative test finding.

Results

At baseline, 22 of 45 patients had negative PLR 1 in the PROP group, whereas 20 of 46 patients had negative PLR 1 in the DEX group. After propofol or dexmedetomidine sedation, there were significant decreases in CI (−9.5% [±6.6%] versus −16.4% [±8.5%], P < 0.001) in the PROP and DEX groups, respectively. In the PROP group, there were significant increases in CI (+18.4% [±9.5%] versus +10.7% [±12.3%], P < 0.05) induced by PLR 2 compared with that induced by PLR 1. In the DEX group, there were no significant increases in CI (+13.2% [±14.9%] versus +12.8% [±17.7%]) induced by PLR 2 compared with that induced by PLR 1. Although the mean arterial pressure values increased comparably with the volume expansion observed in both groups, the volume expansion resulted in a significantly higher increase in CI compared with the baseline values in the PROP group (3.2 ± 0.8 versus 3.2 ± 0.7 L/min/m²) but not in the DEX group (2.9 ± 0.7 versus 3.1 ± 0.8 L/min/m², P < 0.05).

Conclusions

We observed that propofol infusion, but not dexmedetomidine infusion, can increase preload dependency and fluid responsiveness in patients with circulatory failure.     

Successful strategies for the reduction of operating room turnover times in a tertiary care academic medical center

Background

Turnover time (TOT) is one of the classic measures of operating room (OR) efficiency. There have been numerous efforts to reduce TOTs, sometimes through the employment of a process improvement framework. However, most examples of process improvement in the TOT focus primarily on operational changes to workflows and statistical significance. These examples of process improvement do not detail the complex organizational challenges associated with implementing, expanding, and sustaining change.

Methods

TOT data for general and gastrointestinal surgery were collected retrospectively over a 26-mo period at a large multispecialty academic institution. We calculated mean and median TOTs. TOTs were excluded if the sequence of cases was changed or cases were canceled. Data were retrieved from the perioperative nursing data entry system.

Results

Using performance improvement strategies, we determined how various events and organizational factors created an environment that was receptive to change. This ultimately led to a sustained decrease in the OR TOT both in the general and gastrointestinal surgery ORs that were the focus of the study (44.8 min versus 48.6 min; P < 0.0001) and other subspecialties (49.3 min versus 53.0 min; P < 0.0001), demonstrating that the effect traveled outside the study area.

Conclusions

There are obstacles, such as organizational culture and institutional inertia, that OR leaders, managers, and change agents commonly face. Awareness of the numerous variables that may support or impede a particular change effort can inform effective change implementation strategies that are “organizationally compatible.”     

Preventive effect of phosphodiesterase 5 inhibitor Tadalafil on experimental post-pyelonephritic renal injury in rats

Background

To evaluate the effects of Tadalafil, a phosphodiesterase 5 enzyme inhibitor, on Escherichia coli–induced renal damage in an acute pyelonephritis (PN) rat model.

Methods

Experimental PN was induced in 32 Wistar rats, and four groups were formed: group 1 (no treatment), group 2 (antibiotic), group 3 (Tadalafil), and group 4 (antibiotic + Tadalafil). Antibiotic was given on days 3 to 8, and Tadalafil was administered between days 0 and 28 of bacterial inoculation. Half of the rats were killed on the ninth day (early period) and histopathological parameters, immunohistochemical renal fibrosis markers, and oxidant/antioxidant system activities were evaluated. The rest of the rats were killed at the sixth week of the study and evaluated for histopathological parameters and renal fibrosis markers.

Results

Inflammatory activity was significantly milder in rats treated with antibiotic + Tadalafil versus no treatment group both in the early and late periods. In the late period, interstitial fibrosis or tubular atrophy was lower in the antibiotic + Tadalafil group versus the no treatment and antibiotic groups, and in Tadalafil versus antibiotic group. Tadalafil administration significantly reduced renal malondialdehyde and nitric oxide levels and enhanced superoxide dismutase and catalase activities. In addition, circulating tumor necrosis factor α, interleukin 1β was greatly reduced in Tadalafil group versus the no treatment group.

Conclusions

We have provided the first evidence that phosphodiesterase 5 enzyme inhibitor Tadalafil ameliorates circulating inflammatory cytokines, reverses oxidant/antioxidant dysfunction and eventually possesses an overall protective effect on renal tissue from Escherichia coli–induced PN-related kidney injury. Phophodieterase 5 inhibitor might be a novel therapeutic target for PN.     

Impact of oxygen free radicals in rat partial liver transplantation

Background

Due to the shortage of suitable organs, the demand for partial liver transplantation from living donors has increased worldwide. N-acetylcysteine (NAC) has shown protective effects as a free radical scavenger during hypothermic preservation and warm ischemia–reperfusion liver injury; however, no study has reported the effects in partial liver transplantation. The aim of this study was to analyze the impact of NAC on liver graft microcirculation and graft function after partial liver transplantation in rats.

Methods

Orthotopic partial liver transplantations were performed in 40 rats following cold storage in histidine-tryptophan-ketoglutarate solution for 3 h with 20 mM NAC (NAC group, n = 20) or without (control group, n = 20). We assessed portal circulation, graft microcirculation, and biochemical analyses of plasma at 1, 3, 24, and 168 h after portal reperfusion.

Results

(Control versus NAC, median and range): Portal venous pressure was significantly lower with NAC (P = 0.03). Microcirculation measured by laser Doppler was significantly improved with NAC throughout the time course (P = 0.003). Alanine aminotransferase levels were significantly lower in the NAC group (P < 0.05). Total antioxidative capacity was significantly higher in the NAC group at 1 h after reperfusion (Trolox equivalents: median, 3 μM; range, 2.9–6.7 versus median, 16.45 μM; range, 10.4–18.8). Lipid peroxidation was significantly abrogated in the NAC group (median, 177.6 nmol/mL; range, 75.9–398.1 versus median, 71.5 nmol/mL; range, 58.5–79 at 3 h).

Conclusions

This study showed that NAC treatment during cold storage resulted in improved microcirculation and preservation quality of partial liver graft likely because of enhanced antioxidant capacity and reduced lipid peroxidation.     

Effect of tramadol on fentanyl induced cough: A double-blind,randomized, controlled study

BackgroundTramadol has NMDA antagonist effect and reported to have antitussive effect. The aim of this study to assess the effect of preoperative i.v. tramadol compared to placebo on the incidence and severity of fentanyl induced cough.MethodIn a prospective, randomized, double-blind study, 100 patients ASA I, age 18–50 years old, scheduled for elective laparoscopic surgeries under general anesthesia. Patients were randomly allocated to one of two groups: Tramadol group received i.v. tramadol 1 mg/kg in 100 ml saline and control group received 100 ml saline over 15 min before induction of anesthesia. The incidence and severity of cough was assessed following injection of fentanyl 2 μg/kg. The postoperative analgesic requirements, nausea, and vomiting were also recorded.ResultsThe incidence of FIC was significantly less in tramadol treated group being [10 (20%)], compared to control group being [19 (38%)] (p < 0.05). Regarding the grade of FIC; 7 out of 10 in tramadol group and 12 out of 19 in control group showed mild form, 3 out of 10 in tramadol group and 4 out of 19 in control group showed moderate form and 3 out of 19 in control group with no patients in tramadol group showed severe form. The postoperative analgesic requirements was significantly less in tramadol group (p < 0.05) with no significant difference in postoperative nausea and vomiting between the two groups.ConclusionTramadol 1 mg/kg i.v. infusion 15 min before induction of anesthesia reduced the incidence and severity of cough after fentanyl injection 2 μg/kg with reduction of postoperative analgesic requirements and without changes in postoperative nausea and vomiting compared to placebo.     

Remote ischemic perconditioning protects the liver from ischemia–reperfusion injury

Background

Ischemia–reperfusion (IR)–induced injury is a frequent sequel of major liver resections. IR injury after prolonged surgical interventions could be the source of increased risk of postoperative morbidity and mortality. Hepatoprotective effects of this new feasible method called remote ischemic perconditioning (RIPER) were investigated in our rat model of IR injury.

Materials and methods

Male Wistar rats underwent ischemia for 60 min on two-thirds of their livers, followed by 1, 6, and 24 h of reperfusion (n = 72, 8 per group). During liver ischemia, but before reperfusion, rats in the treated groups received four cycles of brief infrarenal aortic clamping as perconditioning. Liver microcirculation was monitored by laser Doppler flowmeter parallel with mean arterial pressure measurements. Liver tissue injury and redox homeostasis were investigated. Furthermore, serum tumor necrosis factor alpha (TNF-α) levels were measured.

Results

In the RIPER group, compared with the IR group, serum transaminase levels were significantly lower after each reperfusion period (alanine aminotransferase: 1 h, P < 0.001; 6 h, P < 0.05; 24 h, P < 0.01 and aspartate aminotransferase: 1 h, P < 0.001; 6 h, P < 0.05; 24 h, P < 0.05). Reperfusion microcirculatory parameters significantly improved in the perconditioned group compared with those in the IR group (reperfusion area: P = 0.005; maximal plateau: P = 0.0002). Regarding TNF-α levels, significant differences were detected between the two IR injured groups (RIPER versus IR: 1 h, 34.3 ± 12.8 pg/mL versus 205.7 ± 60.9 pg/mL, P < 0.001; 6 h, 60.6 ± 11.7 pg/mL versus 110.4 ± 21.6 pg/mL, P < 0.05). Results of the histologic assessment and redox state measurements also showed favorable changes.

Conclusions

Our team firstly reported the protective effects of RIPER on liver morphology, redox homeostasis, and microcirculation and proposed the changes of TNF-α expression.     

Morbidity of peripherally inserted central catheters in pediatric complicated appendicitis

Background

The purpose of this study was to compare postoperative outcomes of pediatric patients with complicated appendicitis managed with or without a peripherally inserted central catheter (PICC).

Methods

Patients aged ≤18 y in the Pediatric Health Information System database with complicated appendicitis that underwent appendectomy during their index admission in 2000–2012 were grouped by whether they had a PICC placed using relevant procedure and billing codes. Rates of subsequent encounters within 30 d of discharge along with associated diagnoses and procedures were determined. A propensity score–matched (PSM) analysis was performed to account for differences in baseline exposures and severity of illness.

Results

We included 33,482 patients with complicated appendicitis; of whom, 6620 (19.8%) received a PICC and 26,862 (80.2%) did not. The PICC group had a longer postoperative length of stay (median 7 versus 5 d, P < 0.001) and were more likely to undergo intra-abdominal abscess drainage during the index admission (14.4% versus 2.1%, P < 0.001), and have a reencounter (17.5% versus 11.4%, P < 0.001) within 30 d of discharge. However, in the PSM cohort (n = 4428 in each group), outcomes did not differ between treatment groups, although the PICC group did have increased odds for the development of other postoperative complications (odds ratio = 3.95, 95% confidence interval: 1.45, 10.71).

Conclusions

After accounting for differences in severity of illness by PSM, patients managed with PICCs had a similar risk for nearly all postoperative complications, including reencounters. Postoperative management of pediatric complicated appendicitis with a PICC is not clearly associated with improved outcomes.     

Assessment of surgical residents in a vascular anastomosis laboratory

Background

We designed a simple, low-cost workshop to teach surgical residents the basic skills of vascular anastomosis. We studied our ability to identify objective procedural and end-product metrics that could be used to measure improvement in vascular anastomotic skill before and after training.

Materials and methods

Ten postgraduate year 2 residents without previous vascular surgery experience and four attending surgeons (expert) performed end-to-side anastomosis using a synthetic graft. The residents were taught the basic skills of vascular anastomosis during three didactic workshops. The objective metrics included volume leakage after saline perfusion (leak) and the time needed to complete the anastomosis. Penalty points were assigned for broken sutures, air knots, locking sutures, and failure to maintain an outside-in to inside-out technique. The leak, time, and penalties before and after training were compared.

Results

The mean leak was 70.4 ± 13.7 mL and the mean completion time was 18.7 ± 3 min for the pretraining group versus 45.3 ± 10.6 mL (P < 0.01) and 8.5 ± 1 min (P < 0.001), respectively, for the attending group. After training, significant improvement was seen in resident leak (46.7 ± 6.8 mL; P < 0.001) and completion time (14.4 ± 3 min; P < 0.01). Leak was similar between the post-training and expert groups (46.7 ± 6.8 mL and 45.3 ± 10.6 mL, respectively; P = 0.77); however, a significant difference for the completion time remained (14.4 ± 3.0 min and 8.5 ± 1 min, respectively; P < 0.01). The mean number of technical errors improved from 2.7 in the pretraining group to zero for the post-training group after completing the workshop.

Conclusions

We have reported an easy to implement workshop for teaching surgical residents the basic skills of performing vascular anastomosis.