Remifentanil for the insertion and removal of long-term central venous access during monitored anesthesia care

Study Objective

To determine the analgesic efficacy of three different rates of remifentanil infusion in patients undergoing insertion or removal of long-term central venous access devices during monitored anesthesia care and local anesthetic field infiltration.

Design

Double-blinded, randomized, controlled study.

Setting

Operating theatre of an University hospital.

Patients

44 unpremedicated, ASA physical status 1 and 2 patients, aged 18-65 years, undergoing insertion or removal of a Port-a-Cath or Hickman catheter.

Interventions

Patients sedated with a propofol target-controlled infusion were randomly allocated to three groups: Group R25 (n = 14), Group R50 (n = 15), and Group R75 (n = 15), to receive remifentanil 0.025, 0.05, and 0.075 μg/kg/min, respectively. Rescue remifentanil 0.5 μg/kg was administered for pain scores > 3. The remifentanil infusion rate was maintained constant unless respiratory and/or cardiovascular unwanted events occurred, whereupon the rate was adjusted in 0.01 μg/kg/min decrements as necessary.

Measurements

Pain scores (primary outcome), sedation, and movement scores (secondary outcomes) were assessed during local anesthetic infiltration of the anterior chest wall and 5 other procedural steps.

Main Results

All infusion rates had equal analgesic efficacy, as shown by comparable pain scores, number of rescue boluses, and number of patients requiring rescue analgesia. Excessive sedation was associated with the highest remifentanil rate such that Group R75 patients were significantly more sedated than Groups R25 or R50 at selective procedural steps (P < 0.05). More Group R75 patients (6/15) required remifentanil rate reduction than did patients from Group R50 (1/15) or Group R25 (0/14), P < 0.01, most commonly because of respiratory depression.

Conclusions

For the insertion or removal of long-term central venous access devices, all three remifentanil infusion rates proved to be equally analgesic-efficient. However, the excessive sedation and tendency to respiratory and cardiovascular events associated with the highest remifentanil infusion rate renders such a rate less desirable for this purpose.     

Anti-γ Chain and Anti-IL-2Rβ mAbs in Combination With Donor Splenocyte Transfusion Induce H-Y Skin Graft Acceptance in Murine Model

Background

The common cytokine receptor γ chain signals regulate proliferation, differentiation, and apoptosis of peripheral T cells.

Objective

To investigate whether simultaneous blockade of IL-2Rβ and γ chain signaling in combination with donor splenocyte transfusion (DST) induces transplant tolerance.

Materials and Methods

C57BL/6 (H-2b) mice were randomly divided into 5 groups. In group 1, female mice received only H-Y skin grafts. In group 2, female mice received transfused splenocytes (5 × 10⁶ cells) from syngeneic male mice on day 7 before H-Y skin grafting. In group 3, on days 2 and 4 after DST, female mice received intraperitoneal injections of a mixture of anti-IL-2Rβ monoclonal antibody (mAb) and anti-γ chain mAbs (4G3, 3E12, and TUGm2; 0.5 mg). After DST, group 4 received an intraperitoneal injection of the mixture of anti-γ chain mAbs, and group 5 received intraperitoneal injection of anti-IL-2Rβ mAb (TM-β1). On day 7, H-Y skin grafting was performed.

Results

Group 3 recipients accepted H-Y skin grafts for more than 100 days compared with group 1 (mean survival time [MST], 33.42 days), group 2 (MST, 14.71 days), group 4 (MST, 58.71 days), and group 5 (MST, 17.29 days). Statistical differences (P < .05) were observed between any 2 groups except groups 2 and 5.

Conclusion

Blockade of γ chain signaling rather than IL-2Rβ signaling combined with DST prolongs H-Y skin graft survival. Simultaneous blockade of IL-2Rβ and γ chain signaling may strengthen this effect.     

Rising incidence of gastroschisis and exomphalos in New Zealand

Background

An apparent increase in the incidence of gastroschisis and exomphalos has been reported from several parts of the world. The exact mechanism of this trend is unknown. The aim of this study was to determine the regional and national trends in the incidence of gastroschisis and exomphalos in New Zealand.

Material and Methods

This retrospective multicenter study involved collection of data from all 4 tertiary care pediatric surgical centers in New Zealand. The incidence was calculated per 10,000 live births. Data were analyzed to determine the regional and national trends. The statistical analysis was done using linear regression model and Poisson distribution.

Results

The incidence of gastroschisis has increased from 2.96 per 10,000 live births to 5.16 per 10,000 live births between 1996 and 2004. During the same period, the incidence of exomphalos has increased from 0.69 per 10,000 live births to 3.27 per 10,000 live births. Gastroschisis was observed more in younger mothers, whereas exomphalos was associated with older mothers.

Conclusion

The incidence of gastroschisis and exomphalos is increasing in New Zealand, which is consistent with worldwide trends in showing the increasing incidence of anterior abdominal wall defects.     

Risk factors and management of intra-abdominal infection after extended radical gastrectomy

Background

This study elucidated risk factors and management for intra-abdominal infection after extended radical gastrectomy.

Methods

From 1988 to 2004, 2,076 patients with gastric cancer underwent extended radical gastrectomy at Taipei Veterans General Hospital. Risk factors for intra-abdominal infection were determined by analyzing clinicopathological factors, operative procedure, combined organ resection, operative time, blood loss, and associated disease(s). Management modalities were summarized.

Results

The overall complication rate was 18.7%. Eighty (3.9%) patients were found to have intra-abdominal infections. Age, prolonged operation time, and combined organ resection were the precipitating factors. These patients were categorized into 3 groups: intra-abdominal abscess with adequate drainage, intra-abdominal abscess without anastomotic leakage, and intra-abdominal abscess because of leakage. Adequate drainage was the primary treatment. Mortality rate was 22.5% (18), and the most common cause of mortality was intra-abdominal abscess caused by leakage.

Conclusions

Although expert surgical skills can minimize the incidence of intra-abdominal infection, management also requires experience and training.     

Using the Clavien Grading System to Classify the Complications of Right Hepatectomy in Living Donors

Introduction

The ratios of complications for living related liver donors after right hepatectomy differ widely among numerous single institutions. This study sought to use the Clavien classification system to define and graded the severity of these complications.

Materials and methods

This study retrospectively analyzed the outcomes of 160 consecutive living donor right hepatectomies performed between July 2002 and February 2008. Complications among living donors for liver transplantation after right hepatectomy were stratified according to the Clavien classification of postoperative surgical complications.

Results

Fifty-two living donors displayed one or more perioperative complications Grade 1 complications were recorded in 18.1%; grade 2 in 6.3%; grade 3a in 5%; and grade 3b in 3.1%. Biliary complications were the most frequent. No donor mortality was present in this series.

Conclusions

The Clavien grading system is useful to comparise surgical outcomes. This study demonstrated that donor right hepatectomy was a relatively safe procedure, but reducing donor complications after right hepatectomy has to be the first priority during the entire process of living related transplantation.     

Polymorphisms of Interleukin-6 and Tumor Necrosis Factor Gene Promoters and Cardiorespiratory Function Following Liver Transplantation: A Preliminary Study

Introduction

The interindividual variability in cardiorespiratory function during liver transplantation (OLT) has been attributed to various factors, including polymorphisms in immunity genes known to affect the circulation levels of cytokines.

Aim

To evaluate polymorphisms of genes encoding for interleukin-6 (IL6) and tumor necrosis factor (TNF) in association with cardiorespiratory function in OLT.

Design

Prospective observational study.

Patients and methods

We studied 62 consecutive patients who had OLT performed in our hospital between 2004 and 2005. Polymorphisms at positions −308 and −409 of TNF gene, as well as those at −174 and −574 of IL6 gene were determined in all patients by means of PCR-RFLPs. Associations were carried out using chi-square tests and analysis of variance. A bilateral P < .05 was accepted as significant.

Results

No statistically significant associations were observed.

Conclusions

A relationship between the polymorphisms studied and respiratory function in OLT was lacking. These results must be interpreted with caution due to the limited sample size.     

Intravenous landiolol, a novel β(1)-adrenergic blocker, reduces the minimum alveolar concentration of sevoflurane in women

Study Objective

To investigate the effect of intravenous (IV) landiolol, a novel β₁-adrenergic blocker, on the minimum alveolar concentration (MAC) of sevoflurane in adult women.

Design

Prospective, randomized study.

Setting

University hospital.

Patients

42 ASA physical status 1 and 2 women, aged 24-57 years, who were scheduled to undergo elective abdominal surgery.

Interventions

Anesthesia was induced in all patients by vital capacity rapid inhalation induction of sevoflurane. In the landiolol group, administration of landiolol began when patients took a vital-capacity breath: 0.125 mg/kg/min for one minute and then 0.04 mg/kg/min. Normal saline was administered in the control group.

Measurements

MAC was determined by a technique adapted from the conventional up-down method.

Main Results

The MAC of sevoflurane was 2.2% ± 0.2% in the control group and 1.7% ± 0.2% in the landiolol group, a statistically significant difference (P = 0.0005).

Conclusions

IV landiolol reduces the MAC of sevoflurane in women by approximately 20%.     

Bacillus Calmette-Guérin without maintenance therapy for high-risk non-muscle-invasive bladder cancer

Background

Bacillus Calmette-Guérin (BCG) is the standard intravesical treatment of high-risk noninvasive (Ta, T1, Tis) bladder cancer. Maintenance BCG is recommended for maximum efficacy.

Objective

We compared our results in a large cohort of high-risk bladder cancer patients who received BCG without maintenance with published results from randomized maintenance BCG trials.

Design, setting, and participants

A cohort of 1021 patients underwent restaging transurethral resection for high-risk (Ta, T1, Tis) bladder cancer.

Intervention

Patients received a 6-wk induction course of BCG therapy. Responding patients did not receive maintenance BCG. Relapsing patients were eligible for retreatment with BCG. All patients were followed for a minimum of 5 yr.

Measurements

End points were 5-yr tumor- and progression-free survival rates.

Results and limitations

Of 816 complete responders to induction BCG, 2- and 5-yr recurrence-free survival rates were 73% and 46%, respectively. The progression-free survival rate was 89%. Progression-free survival time was 56 mo (95% confidence interval, 55-58 mo). Thirty-two percent of the patients required another course of BCG therapy. We cannot exclude that maintenance BCG may benefit patients beyond 5 yr over induction BCG alone and selective BCG retreatments.

Conclusions

Our results with BCG treatment without maintenance of patients with high-risk non-muscle-invasive bladder cancer compare favorably with trials in which comparable patients received maintenance BCG.     

Population-based comparison of open vs laparoscopic esophagogastric fundoplication in children: application of the Agency for Healthcare Research and Quality pediatric quality indicators

Background/Purpose

Increasing national focus on patient safety has promoted development of the pediatric quality indicators (PDIs), which screen for preventable events during provision of health care for children. Our objective is to apply these safety metrics to compare 2 surgical procedures in children, specifically laparoscopic and open esophagogastric fundoplication for gastroesophageal reflux.

Methods

A retrospective analysis using 20 years of data from national representative state inpatient databases through the Healthcare Cost and Utilization Project was conducted. Patients younger than 18 years with International Classification of Diseases, Ninth Revision, Clinical Modification, codes for open or laparoscopic esophagogastric fundoplication were included. Pediatric quality indicators were linked to each patient's profile. Demographics, comorbidities, outcomes, and 8 selected PDIs between open and laparoscopic fundoplications were compared using Pearson χ² tests and t tests.

Results

Of 33,533 patients identified, 28,141 underwent open and 5392 underwent laparoscopic fundoplication. Comorbidities occurred more frequently in open surgery. In-hospital mortality, length of stay, and hospital charges were less in laparoscopic surgery. Of the 8 PDIs evaluated, decubitus ulcer (P = .04) and postoperative sepsis (P = .003) had decreased rates with laparoscopic surgery compared with open.

Conclusion

Laparoscopic fundoplication for gastroesophageal reflux in children can be performed safely compared with the open approach with equivalent or improved rates of PDIs.     

A comparative study of the traditional method, and a point-score system for allocation of deceased-donor kidneys: a national multicenter study in Mexico

Background

The National Transplant Center in Mexico has ruled that deceased-donor kidney allocation is a function of each hospital's Internal Transplant Committee. The aim of this study was to compare and analyze results for of the traditional method and a point-score system in the allocation of deceased patient's kidneys.

Methods

The 12 major kidney transplant centers in the country having a deceased-donor program were invited to participate. Only 3 of them replied to the invitation during 2010. A point-score system was proposed to them, comprising blood group, waiting list time, HLA type, and donor and recipient ages. Once the final recipient was chosen, an explanation of reasons for the choice was requested. Thirty-eight transplants were presented. Kappa coefficient was used to measure degree of agreement in both allocation systems.Organs donated for transplantation came from patients between 4 and 54 years old, including 52% female, 52% O+ blood type, 31% A+, and 11% B+, 44% cranial-encephalic trauma, and 44% brain hemorrhage.

Results

Global agreement was 52.6% (kappa = 0.343), and partial agreement was 76.3% (weighted kappa = 0.204), assigning more intensity to extreme values, but with a lower correlation index. A more intense agreement, without discriminating by hospital, was found for “A” category (blood group), followed by “B” category (waiting list time).

Discussion

Taking into consideration the determining factors for long-term graft survival, it is indispensable to include criteria such as donor and recipient ages and HLA typife in the allocation process. This first draft of a point-score system in organ allocation included waiting list time, blood group, urgency related to vascular/peritoneal access for dialysis, clinical condition, donor/recipient age ratio, and HLA antigenic compatibility.     

Impact of surgery on immunologic function: comparison between minimally invasive techniques and conventional laparotomy for surgical resection of colorectal tumors

Background

Surgical trauma suppresses host immune function, potentially creating an environment vulnerable to tumor cell growth. This study compared immune function after laparoscopy, minilaparotomy, and conventional colorectal tumor resections.

Methods

Seventy-one patients underwent surgery (20 laparoscopy, 21 minilaparotomy, and 30 conventional). Blood samples were taken before surgery and at 3 hours, 24 hours, and 5 days after surgery. White blood cell constitution was determined using monoclonal antibodies. Levels of TH1 cytokines interferon-γ, tumor necrosis factor-α, and interleukin (IL)-2 and TH2 cytokines IL-10, -4, and -6 were measured in plasma and from supernatants of activated peripheral blood mononuclear cells.

Results

At 5 days after surgery, lymphocyte counts remained low in the conventional and minilaparotomy groups (P = .001 and P = .008) but had resolved in laparoscopic patients. Three-hour postoperative serum IL-6 concentrations were lower in laparoscopic than in conventional patients (P = .028). Production of TH1 cytokines 3 hours after surgery were significantly increased in laparoscopic patients (interferon-γ P = .018, tumor necrosis factor-α P = .011, and IL-2 P = .037).

Conclusions

TH1 lymphocyte function is improved transiently and immune homeostasis restored earlier in patients undergoing laparoscopic colorectal cancer resection, which may influence disease recurrence.     

Extracorporeal membrane oxygenation as a bridge to definitive tracheal reconstruction in neonates

Purpose

Infants born with severe tracheal anomalies may not survive beyond the first few hours of life without aggressive cardiopulmonary support and/or emergent airway surgery. The purpose of this study was to review our experience with critically ill neonates supported on extracorporeal membrane oxygenation (ECMO) before tracheal reconstruction.

Methods

A retrospective review of a single institution ECMO registry was conducted. Outcomes of neonates requiring tracheal repair were examined.

Results

Three children with tracheal anomalies (complete tracheal rings [n = 2]; bronchogenic cyst [n = 1]) underwent definitive airway reconstruction. All were placed on ECMO (venovenous [n = 2]; venoarterial [n = 1]) within 24 hours after birth. Tracheoplasties (tracheal resection with end-to-end anastomosis [n = 1]; slide tracheoplasty [n = 1]; carinal resection and reconstruction [n = 1]) were performed at 3.7 ± 2.2 days of life. There were no hemorrhagic or thrombotic complications for an ECMO time of 117.3 ± 60.1 hours. The postoperative durations until extubation and hospital discharge were 12.0 ± 3.2 and 34.3 ± 11.6 days, respectively. All children remain alive and well without cardiopulmonary and neurologic sequelae at a mean follow-up of 4.5 years.

Conclusions

Excellent clinical outcomes can be achieved in neonates born with severe tracheal anomalies using ECMO as a bridge to definitive tracheal reconstruction.     

Isolated cardiac sarcoidosis in heart transplantation

Background

Heart transplantation is the ultimate treatment for end-stage heart failure. Cardiac sarcoidosis has rarely been reported in heart transplantation worldwide. Their long-term prognosis after heart transplantation is unknown. Herein we have presented clinical and pathological observations among heart transplantation patients with isolated cardiac sarcoidosis.

Methods

From 1987 to 2011, we performed 411 heart transplantations including five patients retrospectively reviewed due to the presence of sarcoidosis and giant-cell cardiomyopathy in the recipient heart.

Results

Among the heart transplantations from 2003 to 2011, the four male and one female patients were ages 31 to 40 years. None of them had extra-cardiac sarcoidosis. All five subjects presented with dilated cardiomyopathy with patent coronary arteries. The commonest clinical presentations were atrioventricular block, ventricular arrhythmia, electrocardiographic findings of ST elevations, and poor left ventricular ejection fractions (17%-23%). All patients survived without allograft heart failure to date with the longest survivor at 8 years postoperatively. No recurrence of sarcoidosis has been observed clinically or among the post-heart transplantation endomyocardial biopsies.

Conclusion

Heart transplantation is a useful treatment for isolated cardiac sarcoidosis patients suffering end-stage heart failure. Often the diagnosis is difficult to establish before heart transplantation despite endomyocardial biopsy. No recurrence of sarcoidosis was observed among the allografted hearts.     

Biomechanical evaluation of the expansive cannulated screw for fixation of femoral neck fractures

Background

Femoral neck fracture is one of the common clinical traumas, especially amongst elder patients. This study aims to test, compare and evaluate the bone-screw interface strengths, the fatigue strengths, and the stabilities of our newly designed expansive cannulated screw (ECS) and the common cannulated compression screw (CCS) in the fixation of femoral neck fracture, which is a summary of recent research.

Methods

Twenty-four pairs (48) of fresh femur specimens were randomly divided into four groups with six pairs (12) in each. To simulate one-legged standing, the maximum compressive strength and the single-screw axial pull-out force were compared between the fixed femoral necks treated with two ECSs and two CCSs, two ECSs and three CCSs or three ECSs and three CCSs, respectively. The screws were also subjected to 1 000 000 cycles of a loaded fatigue test and the results were recorded.

Findings

When the same number of screws was used, the ECS showed significantly greater maximum compressive strength than the CCS (P < 0.05), but no significant difference in fixation effectiveness was detected between the two ECSs and the three CCSs groups. The maximum axial pull-out strength of the ECS was also significantly greater that of the CCS (P < 0.01); however, there was no sign of fatigue in both the ECS and CCS after 1 000 000 cycles of loaded fatigue test.

Interpretation

The ECS shows better fixation performance than the currently and commonly used CCS; under certain circumstances, fixation with two ECSs can achieve the same effect as that with traditional three CCSs.     

Thirteen cases of isolated tubal torsions associated with hydrosalpinx in children and adolescents, proposal for conservative management: retrospective review and literature survey

Background/Purpose

Isolated tubal torsion associated with hydrosalpinx is a rare pathology. Our goal was to analyze the clinical and imaging features and discuss the different treatment options available.

Methods

We retrospectively reviewed all the cases of adnexal torsion treated in our department of pediatric surgery over a 10-year period. We searched 2 electronic databases (Medline and Sciencedirect) and targeted reports published during the same period using the key words tubal torsion and hydrosalpinx.

Results

A total of 13 cases, 6 from our hospital and 7 in the medical literature, were identified and analyzed. In 9 (69%) of 13 cases (n = 9/13), torsion and hydrosalpinx occurred on the left fallopian tube. Salpingectomy was performed in 11 of the patients. The resected tubes showed the persistence of ciliated cells associated with signs of moderate ischemic infarction in 50% (n = 3/6) of the cases.

Conclusions

Isolated tubal torsion associated with hydrosalpinx is too often misdiagnosed and treated by salpingectomy regardless of the negative impact on the future reproductive potential of our young patients. As is commonly advocated for ovarian salvage in adnexal torsions, tubal conservation should be favored when possible.     

Association of rs10918594 polymorphisms of nitric oxide synthase 1 adaptor protein (NOS1AP) with QTc interval prolongation during kidney transplantation

Background

The mechanisms of sudden cardiac death are difficult to recognize, but repolarization disturbances have been shown to be the cause. The purpose of this study was to investigate whether the polymorphism of nitric oxide synthase 1 adaptor protein (NOS1AP) was related to the risk of occurrence of corrected QTc-interval prolongation and ventricular arrhythmias recorded on electrocardiography (ECG) Holter monitoring in kidney transplant recipients.

Study Design

The 75 adult first kidney transplant patients included 43 men with an overall mean age of 45 ± 12 years (range, 20-68). Additional patient monitoring during the procedure and in the postoperative period consisted of a continuous ECG tracing recording and investigation of the rs10918594 NOS1AP polymorphism.

Results

We observed Transient QTc-interval prolongation during the perioperative period. NOS1AP genotypes were in Hardy-Weinberg equilibrium. For further statistical analysis, we combined GG homozygotes and CG heterozygotes because of the small numbers available; therefore, only a dominant mode of inheritance was investigated. There were no gender differences in QTc-interval patterns. Analysis of variance with repeated measures revealed no interaction between NOS1AP and QTc-interval values taken at various times among the kidney recipients.

Conclusions

The transplantation procedure may lead to dynamic repolarization disturbances, which may produce an increased risk of severe arrhythmias despite optimization of patient status. The NOS1AP rs203462 polymorphisms did not correlate with an increased risk of QT interval prolongation among kidney recipients.     

The role of CD14 and Toll-like receptor 4 of Kupffer cells in hepatic ischemia-reperfusion injury in rats

Objective

The objective of this study was to study the role of CD14 and Toll-like receptor 4 (TLR4) in Kupffer cells (KCs) on ischemia reperfusion injury (IRI) in rat liver grafts.

Methods

Isolated KCs were obtained from control, IRI, and IRI plus anti-CD14 antibody groups. We measured messenger RNA (mRNA) and protein expression of the lipopolysaccharide receptor CD14 and TLR4, nuclear factor kappa B (NF-κβ) activity, and TNF-α levels.

Results

mRNA and protein expressions of CD14 and TLR4 were significantly higher in the IRI than in the control group, as were protein expressions of CD14 and TLR4 by flow cytometry and by Western blots. NF-κβ activity and tumor necrosis factor-α level in the IRI group were significantly higher than in the control group (3.17 ± 0.21 and 0.28 ± 0.03 vs 654.2 ± 3.6 pg/mL and 147.4 ± 1.1 pg/mL; t value = 4.11 and 4.29 for each; P < .01). Compared with the IRI group they were greatly decreased after anti-CD14 antibody treatment: 2.14 ± 0.17 vs 3.17 ± 0.21, 298.7 ± 1.8 pg/mL vs 654.2 ± 3.6 pg/mL (t value = 2.52 and 2.92 for each; P < .05). They were still significantly higher than the control group (t values of 3.01 and 3.27 for each; P < .01).

Conclusion

IRI up-regulated CD14 and TLR4 gene expression in KCs, and subsequently activated NF-κβ to produce cytokines.     

Axillary-conserving surgery is facilitated by neoadjuvant chemotherapy of breast cancer

Background

This study examines the downstaging of breast cancer axillary lymph node (ALN) metastasis by neoadjuvant chemotherapy (NCT) and the potential facilitation of axillary-conserving surgery.

Methods

Records of breast cancer patients treated with NCT, breast surgery, and pathological ALN assessment were reviewed using the institutional breast cancer database.

Results

Of 473 cases, 309 (65%) were clinically ALN-positive (cN+) and 164 (35%) were clinically ALN-negative (cN−). Pre-NCT, needle biopsy, sentinel lymph node (SLN) biopsy, or axillary dissection documented metastasis in 94% (117/124) of cN+ and 27% (13/49) of cN− patients tested. Pathological complete response of ALNs to NCT was documented in 36% (41/115) of patients. False negative SLN biopsy following NCT occurred in 4% of cases (1/28).

Conclusion

NCT downstages primary breast cancer and ALN metastasis. ALN and SLN biopsy following, rather than before, NCT facilitate both breast- and axillary-conserving surgery.