Risk of incomplete pyloromyotomy and mucosal perforation in open and laparoscopic pyloromyotomy

Background

Despite randomized controlled trials and meta-analyses, it remains unclear whether laparoscopic pyloromyotomy (LP) carries a higher risk of incomplete pyloromyotomy and mucosal perforation compared with open pyloromyotomy (OP).

Methods

Multicenter study of all pyloromyotomies (May 2007–December 2010) at nine high-volume institutions. The effect of laparoscopy on the procedure-related complications of incomplete pyloromyotomy and mucosal perforation was determined using binomial logistic regression adjusting for differences among centers.

Results

Data relating to 2830 pyloromyotomies (1802 [64%] LP) were analyzed. There were 24 cases of incomplete pyloromyotomy; 3 in the open group (0.29%) and 21 in the laparoscopic group (1.16%). There were 18 cases of mucosal perforation; 3 in the open group (0.29%) and 15 in the laparoscopic group (0.83%). The regression model demonstrated that LP was a marginally significant predictor of incomplete pyloromyotomy (adjusted difference 0.87% [95% CI 0.006–4.083]; P = 0.046) but not of mucosal perforation (adjusted difference 0.56% [95% CI − 0.096 to 3.365]; P = 0.153). Trainees performed a similar proportion of each procedure (laparoscopic 82.6% vs. open 80.3%; P = 0.2) and grade of primary operator did not affect the rate of either complication.

Conclusions

This is one of the largest series of pyloromyotomy ever reported. Although laparoscopy is associated with a statistically significant increase in the risk of incomplete pyloromyotomy, the effect size is small and of questionable clinical relevance. Both OP and LP are associated with low rates of mucosal perforation and incomplete pyloromyotomy in specialist centers, whether trainee or consultant surgeons perform the procedure.     

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.     

Comparison of laparoscopic versus open adrenalectomy: results from American College of Surgeons-National Surgery Quality Improvement Project

Background

Although the existing literature suggests that laparoscopic adrenalectomy may be associated with less postoperative morbidity than open adrenalectomy, a comparison of the two approaches has not been published using American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data. The objective of our analysis was to compare the 30-d outcomes after laparoscopic versus open adrenalectomy using this data source.

Methods

The ACS-NSQIP Participant User Files for 2005–2010 were used for this retrospective analysis, which included all patients with (1) a primary Current Procedural Terminology code for open or laparoscopic adrenalectomy and (2) a postoperative International Classification of Diseases, Ninth Revision (ICD-9) code for adrenal gland pathology. Primary outcomes were 30-d postoperative mortality, overall complication rate, and length of postoperative hospitalization. The association between surgical approach and primary outcomes were determined after adjusting for a comprehensive array of patient- and procedure-related factors.

Results

A total of 3100 patients were included for analysis (644 undergoing open versus 2456 undergoing laparoscopic adrenalectomy). Patients undergoing a laparoscopic procedure had significantly lower postoperative morbidity and shorter length of stay than patients undergoing an open procedure after adjustment for patient- and procedure-related factors. Similar findings were demonstrated for all indications, including malignancy.

Conclusions

To our knowledge, the present study represents the largest comparison to date of laparoscopic versus open adrenalectomy. Our findings suggest that the laparoscopic approach is associated with sizeable reductions in postoperative morbidity and length of postoperative hospitalization.     

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.     

Diabetes remission and glycemic response to pre-bariatric surgery diet

Background

Before bariatric surgery, some patients with type 2 diabetes mellitus (T2DM) experience improvement in blood glucose control and reduced insulin requirements while on a preoperative low-calorie diet (LCD). We hypothesized that patients who exhibit a significant glycemic response to this diet are more likely to experience remission of their diabetes in the postoperative period.

Materials and methods

Insulin-dependent T2DM patients undergoing bariatric surgery between August 2006 and February 2011 were eligible for inclusion. Insulin requirements at day 0 and 10 of the LCD were compared. Patients with a ≥50% reduction in total insulin dosage to maintain appropriate blood glucose control were considered rapid responders to the preoperative LCD. All others were non–rapid responders. We analyzed T2DM remission rates up to 1 y postoperatively.

Results

A total of 51 patients met inclusion criteria and 29 were categorized as rapid responders (57%). The remaining 22 were considered non–rapid responders (43%). The two groups did not differ demographically. Rapid responders had greater T2DM remission rates at 6 (44% versus 13.6%; P = 0.02) and 12 mo (72.7% versus 5.9%; P < 0.01). In patients undergoing laparoscopic gastric bypass, rapid responders showed greater excess weight loss at 3 mo (40.1% versus 28.2%; P < 0.01), 6 mo (55.2% versus 40.2%; P < 0.01), and 12 mo (67.7% versus 47.3%; P < 0.01).

Conclusions

Insulin-dependent T2DM bariatric surgery patients who display a rapid glycemic response to the preoperative LCD are more likely to experience early remission of T2DM postoperatively and greater weight loss.     

Novamin infusion: a new method to cure postoperative shivering with hypothermia

Background

Postoperative shivering is a frequent complication of surgery in developing countries and there is no satisfying method to treat it, let alone to cure it. We studied whether intravenous amino acid (AA) infusion can cure postoperative shivering in the postanesthesia care unit.

Methods

Sixty postanesthesia care unit patients with shivering grade 2 or higher and tympanic temperature <36°C received randomly either infusion of Novamin 18 AAs (2 mL/kg/h), pethidine (0.5 mg/kg), or tramadol (1 mg/kg). Tympanic temperature, shivering grade, and thermal comfort were assessed every 5 min for 60 min. Blood glucose and lactic acid concentrations were measured before and after treatment. Postoperative nausea and vomiting were also recorded.

Results

Shivering stopped within 5 min in the pethidine and tramadol groups versus 90% stopped within 15 min in AA group. There were five cases of reshivering in the tramadol group versus none in the AA or pethidine groups. Tympanic temperature increased slowly in all patients but increased significantly faster in the AA group. Thermal comfort improved significantly faster in the AA group versus the other two groups, thermal comfort was significantly higher in the tramadol versus the pethidine group ≥35 min. Blood glucose concentration in AA group increased to 135.18 ± 9.18 mg/dL. There were some cases of nausea and vomiting in pethidine and tramadol groups but none in the AA group.

Conclusion

Novamin infusion can stop postoperative shivering and alleviates hypothermia and improves thermal comfort more effectively than tramadol and pethidine with less nausea and vomiting and causes a clinically acceptable blood glucose increase with no reshivering episodes.     

Feasibility and safety of single-incision laparoscopic splenectomy: a systematic review

Objective

The aim of this review was to evaluate the feasibility, safety, and potential benefits of single-incision laparoscopic splenectomy (SILS-Sp).

Methods

We conducted a systemic review of literature between 2009 and 2012 to retrieve all relevant articles.

Results

A total of 29 studies with 105 patients undergoing SILS-Sp were reviewed. Fifteen studies used a commercially available single-port device. The range of body mass index was 14.7–41.4 kg/m². Six studies described combined operations including cholecystectomy (n = 8), mesh-pexy (n = 1), and pericardial devascularizaion (n = 1). The ranges of operative times and estimated blood losses were 28–420 min and 0–350 mL, respectively. Of 105 patients, three patients (2.9%) required additional ports, two patients (1.9%) were converted to open, and three patients (2.9%) to conventional multiport laparoscopic splenectomy (overall conversion rate, 4.8%). Postoperative bleeding occurred in two patients (1.9%) who both required reoperation. Overall mortality was 0% (0/105). The length of postoperative stay varied across reports (1–11 d). Among four comparative studies, one showed greater estimated blood loss and lower numeric pain rating scale score in the SILS-Sp group than in the multiport laparoscopic splenectomy group (206.25 ± 142.45 versus 111.11 ± 99.58 mL) and (3.81 ± 0.91 versus 4.56 ± 1.29), respectively. Another comparative study showed that SILS-Sp was associated with a shorter operative time (92.5 versus 172 min; P = 0.003), lower conversion rate, equivalent length of hospital stay, reduced mortality, similar morbidity, and comparable postoperative narcotic requirements.

Conclusions

In early series of highly selected patients, SILS-Sp appears to be feasible and safe when performed by experienced laparoscopic surgeons. However, as an emerging operation, publication bias is a factor that should be considered before we can draw an objective conclusion.     

A comparison of the endoscopic and laparoscopic view of the gastroesophageal junction in the use of transoral fundoplication

Background

Endoscopic fundoplication requires accurate evaluation of the gastroesophageal junction (GJ) to determine if hiatal hernia repair is necessary before fundoplication. We compared the endoscopic and laparoscopic evaluations of the GJ.

Methods

A total of 53 patients with gastroesophageal reflux disease underwent a laparoscopic repair of a hiatal defect before endoscopic fundoplication. The video of the preoperative endoscopic evaluation was compared with the laparoscopic video (n = 44). Nine patients were excluded because both endoscopic and laparoscopic videos were not available. A 2-tailed paired t test was used to assess the difference between the 2 study groups.

Results

The greatest transverse dimension of the hiatus assessed endoscopically was 3.30 cm ± 1.00 vs 3.88 cm ± 1.03 assessed laparoscopically, P < .001. In 22.8%, the average endoscopic Hill grade was lower than the estimated Hill grade when viewed laparoscopically. In 11.1% (range, 6% to 15%) of cases, the endoscopic view indicated a hiatal hernia repair was unnecessary when the matching laparoscopic view indicated hiatal repair would be needed.

Conclusions

Endoscopic evaluation of the GJ may underestimate the radial size of the hiatal defect.     

The role of clinical care pathways: an experience with distal pancreatectomy

Background

Previous studies have indicated that clinical pathways may shorten hospital length of stay (HLOS) among patients undergoing distal pancreatectomy (DP). Here, we evaluate an institutional standardized care pathway (SCP) for patients undergoing DP.

Materials and methods

A retrospective review of patients undergoing DP from November 2006 to November 2012 was completed. Patients treated before and after implementation of the SCP were compared. Multivariable linear regression was then performed to identify independent predictors of HLOS.

Results

There were no differences in patient characteristics between SCP (n = 50) and pre-SCP patients (n = 100). Laparoscopic technique (62% versus 13%, P < 0.001), splenectomy (52% versus 38%, P = 0.117), and concomitant major organ resection (24% versus 13%, P = 0.106) were more common among SCP patients. Overall, important complication rates were similar (24% versus 26%, P = 0.842). SCP patients resumed a normal diet earlier (4 versus 5 d, P = 0.025) and had shorter HLOS (6 versus 7 d, P = 0.026). There was no increase in 30-d resurgery or readmission. In univariate comparison, SCP, cancer diagnoses, intraductal papillary mucinous neoplasm diagnoses, neoadjuvant therapy, operative technique, major organ resection, and feeding tube placement were associated with HLOS; however, after multivariable adjustment, only laparoscopic technique (−33%, P = 0.001), concomitant major organ resection (+38%, P < 0.001), and feeding tube placement (+68%, P < 0.001) were independent predictors of HLOS.

Conclusions

Implementation of a clinical pathway did not improve HLOS at our institution. The increasing use of laparoscopy likely accounts for shorter HLOS in the SCP cohort. In the future, it will be important to identify clinical scenarios most likely to benefit from implementation of a clinical pathway.     

Postoperative pneumoperitoneum on computed tomography: is the operation to blame?

Background

Postoperative radiographs demonstrating pneumoperitoneum are a vexing problem for surgeons. This dilemma stems from uncertainty regarding the length of time for resolution of gas introduced operatively via either an open or a laparoscopic approach. We attempted to quantify the duration of pneumoperitoneum after both laparoscopic and open surgery in an animal model.

Methods

A prospective study using 2 groups of 10 pigs (Sus scrofa) was performed. The animals were assigned to undergo either an exploratory laparoscopy or an open abdominal exploration. Postoperatively, sequential computed tomography (CT) scans were performed to assess for the presence of pneumoperitoneum.

Results

Pneumoperitoneum resolution occurred sooner than average on CT scan in the laparoscopic group when compared to open group (1.79 days vs 4.73 days respectively; P value of .02).

Conclusions

Postoperative pneumoperitoneum resolves more quickly after laparoscopy when compared to open surgery in the porcine model. This information may aid in evaluating postoperative CT scans demonstrating pneumoperitoneum.     

Initial experience with same day discharge after laparoscopic appendectomy for nonperforated appendicitis

Background

Although many laparoscopic procedures are performed on an outpatient basis, patients who have undergone a laparoscopic appendectomy have typically stayed at least overnight. Recently, data in both the pediatric and adult literature suggest that same day discharge (SDD) for acute nonperforated appendicitis is safe and associated with high patient and parent satisfaction. We have recently begun attempting SDD for nonperforated appendicitis, and this study is an analysis of our initial experience.

Methods

A retrospective chart review of all patients who underwent laparoscopic appendectomy for nonperforated appendicitis at our institution from January 2012 to July 2013 was performed. Demographics, length of stay, hospital course, and outcomes were measured. Data are expressed as mean ± standard deviation. Comparative analysis was performed using a t-test.

Results

A total of 588 laparoscopic appendectomies for nonperforated appendicitis were performed over an 18-mo period. Approximately 28% (n = 128) were discharged on the day of surgery. Of the remaining patients, 12.9% (n = 59) stayed overnight for medical reasons, 0.4% (n = 2) stayed for social reasons, 3.9% (n = 18) stayed because the operation ended late in the evening, and 82.8% (n = 381) stayed because of clinical care habits. Compared with patients who stayed overnight, there was no statistically significant difference in readmission rates (0.7% versus 1.9%, P = 0.6%), follow-up before scheduled appointment (5.4% versus 5.4%, P = 1.0), and complication rate (0.7% versus 2.6%, P = 0.3). Patients whose operation ended later in the day had a longer hospital stay. We observed a trend toward more SDDs, the further we got from the initiation of our protocol.

Conclusions

SDD is safe for children undergoing laparoscopic appendectomy for nonperforated appendicitis. The two main barriers to SDD were time of day for the operation and provider habit, both of which improved as more practitioners felt comfortable with the concept. SDD requires extensive education within the hospital system, and we have initiated an aggressive prospective protocol to improve the results.     

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.     

Expanding the indications for laparoscopic retroperitoneal adrenalectomy: experience with 81 resections

Background

Laparoscopic retroperitoneal (RP) adrenalectomy has gained popularity as the preferred approach over transabdominal (TA) method; however, surgeons have been reluctant to offer this operation to obese patients because of the concerns over inadequate working space and overall perceived higher rate of complications. The aim of the present study was to evaluate the feasibility and safety of RP adrenalectomy compared with TA adrenalectomy, specifically in morbidly obese patients.

Methods

All laparoscopic adrenalectomies performed at our institution between 2004 and 2012 were reviewed retrospectively. Presenting features, operative characteristics, and postoperative outcomes were evaluated. Complications were graded using Clavien system. Continuous variables were compared using Student t-test. Categorical variables were compared using χ²-test. Prediction models were constructed using linear or logistic regression as appropriate.

Results

Eighty-one RP and 130 TA procedures were performed, 26 (12.3%) and 60 (28.4%), respectively in obese patients (BMI > 30). Among the obese patients, operative time and estimated blood loss were less for RP (90 versus 130 min; P < 0.001 and 0 versus 50 mL; P < 0.001). Differences in the length of stay, overall mortality, incidence and severity of postoperative complications, and rates of readmission were not statistically significant between RP and TA procedures for all comers and in the obese patients. Controlling the operative characteristics and patient-specific factors, neither operative approach nor obesity was found to independently predict the postoperative complications.

Conclusions

Laparoscopic RP adrenalectomy is a safe and feasible technique for obese patients. In the obese patients and for all comers, it offers shorter operative time, decreased estimated blood loss, with comparable length of stay and morbidity and mortality rates. We therefore recommend that this technique should be considered for patients undergoing adrenal resection.     

Distinguishing classical papillary thyroid microcancers from follicular-variant microcancers

Background

Papillary thyroid microcarcinomas (mPTCs), tumors less than or equal to 1 cm, have been considered the same clinical entity as microfollicular-variant papillary thyroid microcarcinomas (mFVPTCs). The purpose of this study was to use population-level data to characterize differences between mFVPTC and mPTC.

Materials and methods

We identified adult patients diagnosed with mFVPTC or mPTC between 1998 and 2010 in the Surveillance, Epidemiology, and End Results database. Binary comparisons were made with the Student t-test and chi-squared test. Multivariate logistic regression was used to further analyze lymph node metastases and multifocality.

Results

Of the 30,926 cases, 8697 (28.1%) were mFVPTC. Multifocal tumors occurred with greater frequency in the mFVPTC group compared with the mPTC group (35.4% versus 31.7%; P < 0.01). Multivariate logistic regression indicated that patients with mFVPTC had a 26% increased risk of multifocality (odds ratio, 1.26; 95% confidence interval, 1.2–1.4; P < 0.01). In contrast, lymph node metastases were nearly twice as common in the mPTC group compared with the mFVPTC group (6.8% versus 3.6%; P < 0.01). Multivariate logistic regression confirmed that patients with mPTC had a 69% increased risk of lymph node metastases compared with patients with mFVPTC (odds ratio, 1.69; 95% confidence interval, 1.4–2.0; P < 0.01).

Conclusions

Multifocality is not unique to classical mPTC and occurs more often in mFVPTC. The risk of lymph node metastases is greater for mPTC than mFVPTC. The surgeon should be aware of these features as they may influence the treatment for these microcarcinomas.     

Reduction of alkaline reflux gastritis and marginal ulcer by modified Braun enteroenterostomy in gastroenterologic reconstruction after pancreaticoduodenectomy

Background

The incidence of alkaline reflux gastritis (ARG) after pancreaticoduodenectomy (PD) is high. Although Braun enteroenterostomy (BEE) may reduce ARG, BEE may result in marginal ulcers (MUs) due to the additional anastomotic stoma. We conducted this study to compare clinical outcomes of using a modified BEE (MBEE) with traditional gastrojejunostomy (TGJ), by inducting a purse-string suture instead of an additional anastomotic stoma.

Materials and methods

All 62 patients underwent standard PD at the Department of Hepatobiliopancreatic Surgery of West China Hospital between January 1, 2008 and January 31, 2012. Demographics, perioperative and postoperative factors, and follow-up morbidity were compared in those patients who underwent MBEE (n = 32, three patients were lost to follow-up) to those who underwent TGJ (n = 30, nine patients were lost to follow-up).

Results

Patients who underwent the MBEE experienced a decrease in total morbidity including ARG and MUs, relative to those who underwent TGJ (24.1% versus 58.3%, P = 0.011). With regard to the MBEE group, the total ARG rate was statistically significantly lower compared with the TGJ group (13.8% versus 37.5%, P = 0.046). In addition, the incidence of MUs was reduced.

Conclusions

In patients undergoing PD, the MBEE was safely performed with significantly more patients having reduced incidence of ARG and related sequela compared with those who underwent TGJ. These results support further study of patients undergoing gastroenterostomy after resection of the distal stomach in larger, randomized studies.     

Clinical outcomes following bowel resection versus reduction of intussusception

Background

Intussusception is most commonly managed with air-contrast reduction. However, when this fails, emergent operation with resection or manual reduction is indicated. It is not known if there are advantages to resection compared with manual reduction.

Methods

A retrospective review of all patients receiving operative care for intussusception from February 2000 to December 2011. Patients undergoing intestinal resection were compared with those treated with manual reduction alone.

Results

Of 111 patients, 49 underwent resection and 62 underwent manual reduction. Mean (±SD) time to oral intake favored manual reduction (2.1 ± 1.2 versus 2.6 ± 1.2 d, respectively, P = 0.05). Manual reduction was associated with a greater need for repeat imaging (47% versus 18%, P = 0.002) and the only recurrences were with manual reduction (8% versus 0%, P = 0.1). Mean duration of stay was no different (P = 0.36), nor was the need for reoperation (P = 0.9).

Conclusions

Patients undergoing manual reduction have an increased number of radiographic imaging procedures. The surgeon should have a low threshold for resection for intussusceptions requiring operative management.     

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.     

Bacterial translocation induces proinflammatory responses and is associated with early death in experimental severe injury

Objective

An experimental model of severe injury with great lethality was studied to define the impact of bacterial translocation on survival and on inflammatory response.

Methods

Forty-one rabbits were divided into two groups: A, femur myotomy; and B, myotomy and fracture of the femoral bone. Vital signs and survival were recorded. Serum circulating endotoxins (lipopolysaccharides; LPS) were determined and tissue cultures were performed at necropsy. A subgroup of animals was sacrificed at 48 h post injury; LPS was determined in abdominal aorta and portal vein, apoptosis of spleen cells was assessed by flow cytometry, and ex vivo production of tumor necrosis factor alpha by splenocytes was measured.

Results

Tissue bacterial burden was increased in animals that died early (i.e., within 48 h after injury) versus rabbits that died later. Portal vein LPS at 48 h was increased in group B compared with group A, whereas circulating LPS did not differ. No difference in apoptosis of either lymphocytes or macrophages of the spleen was found in group B compared with group A. Following stimulation with LPS or phytohemagglutinin, tumor necrosis factor α production by splenocytes of group B was greater than that of group A.

Conclusions

Bacterial translocation primes enhanced proinflammatory responses and it is associated with early death in severe trauma.