Operative repair in congenital diaphragmatic hernia: How long do we really need to wait?

ObjectiveTo analyze preoperative cardiopulmonary support and define preoperative stability relative to timing of surgical repair for CDH neonates not on ECMO.Study designWe retrospectively analyzed repeated measures of oxygenation index (OI; Paw*FiO₂×100/PaO₂) among 158 neonates for temporal preoperative trends. We defined physiologic stability using OI and characterized ventilator days and discharge age relative to delay in repair beyond physiologic stability.ResultsThe OI in the first 24 h of life was temporally reliable and representative of the preoperative mean (ICC 0.70, 95% CI 0.61–0.77). A pre-operative OI of ≤ 9.4 (AUC 0.95) was predictive of survival. Surgical delay after an OI ≤ 9.4 resulted in increased ventilator days (1.4, 95% CI 1.1–1.9) and discharge age (1.5, 95% CI 1.2–2.0). When prospectively applied to a subsequent cohort, an OI ≤ 9.4 was again reflective of physiologic stability prior to repair.ConclusionOI values are temporally reliable and change minimally after 24 h age. Delay in surgical repair of CDH beyond initial stability increases ventilator days and discharge age without a survival benefit.Level of evidencePrognosis study, Level III.     

How long should we treat?

Osteoporosis is a chronic disease, for which effective drugs are available. These drugs have reduced the risk of osteoporosis-related fractures in robust trials of 3–5 years duration. There is no evidence of anti-fracture efficacy for treatments of longer duration. The consequences of stopping treatments are very different for the different molecules. Bisphosphonates can be safely discontinued after 3–5 years of treatment if there was optimal adherence and if patients are no longer osteoporotic. This discontinuation cannot be applied in patients with recent fractures or for other treatments. Safety of prolonged treatment is a huge concern which must be managed appropriately. The decision of a prolonged treatment is driven by the underlying risk of fracture. This risk must be assessed regularly in order to share with the patient the benefit-risk ratio of prolonged treatment.     

Serious cerebral venous thrombosis: can we use fibrinolytic?

We report a case of thrombosis of superior sagittal and cavernous sinuses treated by direct instillation of fibrinolytic agents via selective catheterization. Despite risk of bleeding related to the pathology and treatment, no adverse side-effect occurred. This report is unusual regarding the poor initial clinical patient's condition with dilated and unreactive pupil. The good neurologic outcome warrants aggressive treatment in the most severe forms of cerebral venous thrombosis.     

How low can we go?

Editor—In his editorial,¹ Prof. Sneyd stresses the needfor large prospective studies addressing the effect of bispectralindex (BIS) monitoring on the risk of awareness. What may haveescaped him is that preliminary results from just     

How low can we go?

Intraoperative awareness is a terrifying experience, which patientsfear and anaesthetists are anxious to avoid; any clinician whodoubts this should read a first hand account.¹ Since the early1990s, the Bispectral Index (BIS) has been developed as a measureof hypnosis during anaesthesia and sedation. As BIS is a linearizedand monotonic measure, clinicians have become comfortable withthe idea that an increase in BIS may warn of actual or impendingawareness. Although     

How long can patients with renal cell carcinoma wait for surgery without compromising pathological outcomes?

Introduction:

Surgical wait times have been shown to be of significance in other malignancies, but limited studies exist in renal cell cancer (RCC). We analyzed surgical waiting time for RCC patients to see if there was an adverse impact on pathological characteristics.

Methods:

Our centre triages RCC patients on the basis of perceived tumour risk. The waiting time for surgery is adjusted stage for stage: clinical T1 at 90 days, T2 at 40 days, T3 and T4 at 30 days. We retrospectively reviewed the charts of 354 patients who underwent surgery for RCC. Patients were assessed for pathological upstaging, positive lymph nodes, tumour recurrence and tumour size within each stage. Analysis was performed, using surgical waiting time as a categorical variable, to test for associations with disease recurrence or adverse pathological characteristics.

Results:

The median time from the first consultation to surgery was 41 days and the mean follow-up was 26.6 months. Waiting time stage for stage was: clinical T1 at 57.12 days, clinical T2 at 36.8 days, clinical T3 and T4 at 30.32 days. On multivariate analysis, pathological tumour size was associated with progression, whereas no significant association was found between waiting time and upstaging. Higher stage tumours, sarcomatoid pathology and clinical evidence of progression were associated with shorter waiting times for early interventions.

Conclusions:

There was no statistically significant evidence for upstaging or progression during the waiting period for our group of patients. The data reinforce previous studies reporting a “safe” period of active surveillance in T1 RCC without affecting their final pathological outcome.     

How long can we preserve the pulmonary graft inside the nonheart-beating donor?

BACKGROUND: The use of lungs from nonheart-beating donors (NHBD) might significantly alleviate the organ shortage. Extending the preharvest interval in NHBD would facilitate distant organ retrieval. We hypothesized that prolonged topical cooling inside NHBD after 60 minutes of initial warm ischemia would not affect the pulmonary graft. METHODS: Domestic pigs were anesthetized and divided into three groups (n = 6 in each group). In the control group (HBD), lungs were flushed, explanted, and further stored in low potassium dextran solution (4 degrees C) for 4 hours. In the two study groups pigs were sacrificed by myocardial fibrillation and left untouched for 1 hour. Chest drains were then inserted for topical lung cooling (6 degrees C) for 3 hours (NHBD-TC3) or 6 hours (NHBD-TC6). The left lung in all groups was then prepared for evaluation. In an isolated circuit lungs were ventilated and reperfused through the pulmonary artery. Hemodynamic, aerodynamic, and oxygenation variables were measured 35 minutes after onset of controlled reperfusion. Wet-to-dry weight ratio was calculated. RESULTS: No significant differences were observed among the three groups in pulmonary vascular resistance (p = 0.38), mean airway pressure (p = 0.39), oxygenation index (p = 0.62), and wet-to-dry weight ratio (p = 0.09). CONCLUSIONS: These data confirm that 1 hour of warm ischemia does not affect the pulmonary graft from NHBD compared with HBD. The preharvest interval can be safely extended up to 7 hours postmortem by additional topical cooling of the graft inside the cadaver. This technique may facilitate distant organ retrieval in NHBD.     

Teaching laparoscopy to residents: How can we select good candidates?

Modern medicine incorporates minimally invasive approaches in virtually all areas of surgery, and its application will continue to expand. The laparoscopic approach to many complex procedures is accompanied by a long learning curve that is not easily overcome or bypassed. Current training methods involve box trainers, virtual reality simulators, and live animal models that all attempt to replicate laparoscopic scenarios with varying degrees of success. The emphasis in training is now on intensive fellowship courses in high-volume centers that may overcome the learning curves associated with de novo development of laparoscopy. The many attempts to devise tools to assess laparoscopic skills have at best served as tests to discriminate between existing skill levels but do not provide a reliable tool to predict eventual laparoscopic ability. The traditional attributes of sound knowledge and clinical judgement that make a good surgeon are true of a good laparoscopist with perhaps the added requirement of stamina and motivation to complete the arduous training programs that are now needed to become competent in laparoscopy.