Risk factors for contra-lateral hip fracture in elderly patients with previous hip fracture

Introduction

Contra-lateral hip fractures in elderly patients with a previous hip fracture increase the incidence of complications and socioeconomic burden. The purpose of this study was to identify the risk factors that contribute to the occurrence of contra-lateral hip fracture in elderly patients.

Materials and methods

Among 1093 patients treated for a hip fracture, 47 patients sustained a contra-lateral hip fracture. These patients were compared with 141 patients with a unilateral hip fracture (controls).

Results

The incidence of contra-lateral hip fracture was 4.3% among the 1093 patients treated for a hip fracture at our institute. A contra-lateral hip fracture occurred within 2 years of initial fracture in 66%, and subsequently, the annual incidence rate decreased. A similar fracture pattern was noted in 70% of patients who sustained an intertrochanteric fracture. In terms of preoperative factors, respiratory disease (OR 2.57, P = 0.032) and visual impairment (OR 2.51, P = 0.012) were higher in patients with a contra-lateral hip fracture than in controls, and for postoperative factors, the proportions of patients with postoperative delirium (OR 2.91, P = 0.022), late onset of rehabilitation (OR 1.05, P = 0.023), and poor ambulatory status at 3 months (OR 1.34, P = 0.002) were also significantly higher in patients than in controls.

Conclusions

Postoperative delirium and underlying visual impairment and respiratory disease could be risk factors of contra-lateral fracture in elderly patients. Early and active rehabilitation after surgery is important to prevent the occurrence of contra-lateral hip fracture in the elderly.     

Predictors of severe pain in the immediate postoperative period in elderly patients following hip fracture surgery

Introduction

The aim of this study was to identify risk factors for severe postoperative pain immediately after hip-fracture surgery.

Patients and methods

Three hundred forty-four elderly patients with an acute hip fracture were admitted to the hospital during a 12-months period. All patients who entered the study answered a structured questionnaire to assess demographic characteristics, previous diseases, drug use, previous surgery, and level of education. Physical status was assessed through the American Society of Anesthesiologists’ preoperative risk classification, cognitive status using the Short Portable Mental Status Questionnaire, and depression using the Geriatric Depression Scale. The presence of preoperative delirium using the Confusion Assessment Method was assessed during day and night shifts until surgery. Pain was measured using a numeric rating scale (NRS). An NRS ≥7 one hour after surgery indicated severe pain.

Results

Patients with elementary-level education (8 yr in school) presented a higher risk for immediate severe postoperative pain than university-educated patients (>12 yr in school) (P < 0.05). Higher cognitive function was associated with higher postoperative pain (P < 0.01). Patients with symptoms of depression and patients with preoperative delirium presented a higher risk for severe pain (P < 0.05, P < 0.01, respectively). Multivariate analysis showed that depression and a low level of education were independent predictors of severe pain immediately after surgery.

Conclusion

Depression and lower levels of education were independent predictors of immediate severe pain following hip-fracture surgery. These predictors could be clinically used to stratify analgesic risk in elderly patients for more aggressive pain treatment immediately after surgery.     

Is a surgical approach justified for octogenarians with pancreatic carcinoma? Projecting surgical decision making for octogenarian patients

Background

In recent years, more elderly patients have undergone surgery for pancreatic cancer, although the safety and efficacy of performing complex pancreatic resections in patients older than 80 years remain controversial.

Methods

Patients with pancreatic cancer who underwent curative surgical treatment were divided into 2 subgroups: the younger group (<80 years) and the octogenarian group (≥80 years).

Results

From March 2005 to December 2013, 194 consecutive surgically curable patients with diagnosed pancreatic cancer were studied, among which 34 (17.5%) were of 80 years or older. There were no significant differences in postoperative severe complication rates for younger and octogenarian groups (16% vs 20%, respectively) or perioperative mortality rates (1.3% vs .0%). The incidence of postoperative delirium in the octogenarian group was greater than that in the younger group (23.5% vs 3.8%).

Conclusions

Octogenarian pancreatic cancer patients should not be denied a priori the opportunity for surgery, particularly if the patient represents an ideal candidate and if the co-operation of the family can be obtained.     

Measured gap length and outcomes in oesophageal atresia

Aims

Oesophageal atresia (OA) with or without tracheoesophageal fistula (TOF) is the most common congenital anomaly of the oesophagus. There is limited literature suggesting a linear relationship between increasing gap length and the incidence of all major complications. We sought to assess whether measured gap length at the time of surgery was related to outcomes in our patients.

Methods

All patients with a diagnosis of OA +/− TOF who underwent repair under a single surgeon between 1983 and 2012 were included. The length between the oesophageal pouches was measured at the time of surgery. Patients were then divided into three groups; short ≤ 1 cm, intermediate > 1–≤2 cm and long > 2–≤5 cm. Outcome measures were anastomotic leak, strictures requiring dilatation, gastrooesophageal reflux disease (GORD) and need for fundoplication.

Results

122 patients were included in the study. The outcomes for patients with short (n = 53), intermediate (n = 51) and long gaps (n = 18) were as follows: anastomotic leak — 1.9%, 2%, 5.5% (P = 0.66), strictures requiring dilatation — 32%, 33%, 50% (P = 0.67), GORD — 51%, 59%, 72% (P = 0.58) and need for fundoplication — 11%, 20%, 44% (*P = 0.02). There were no deaths related to the repair.

Conclusions

Measured gap length at the time of surgery did not have a linear relationship with leak or stricture rate. Our experience suggests that when primary repair is possible absolute gap length is irrelevant to the development of post-operative complications. There is however a significant increase in the need for fundoplication in those with a long gap.     

Changes in Renal Function Following Nephroureterectomy May Affect the Use of Perioperative Chemotherapy

Background

Nephroureterectomy alone fails to adequately treat many patients with advanced upper tract urothelial carcinoma (UTUC). Perioperative platinum-based chemotherapy has been proposed but requires adequate renal function.

Objective

Our aim was to determine whether the ability to deliver platinum-based chemotherapy following nephroureterectomy is affected by postoperative changes in renal function.

Design, settings, and participants

We retrospectively reviewed data on 388 patients undergoing nephroureterectomy for UTUC between 1991 and 2009. Four institutions were included.

Intervention

All patients underwent nephroureterectomy.

Measurements

All patients had serum creatinine measured before and after surgery. The value closest to 3 mo after surgery was taken as the postoperative value (range: 2–52 wk). Estimated glomerular filtration rate (eGFR) was calculated using the abbreviated Modification of Diet in Renal Disease study equation. eGFR values before and after surgery were compared using the paired t test. We chose an eGFR of 45 and 60 ml/min per 1.73 m² as possible cut-offs for chemotherapy eligibility and compared eligibility before and after surgery using the chi-square test.

Results and limitations

Our cohort of 388 patients included 233 men (60%) with a median age of 70 yr. Mean eGFR decreased by 24% after surgery. Using a cut-off of 60 ml/min per 1.73 m², 49% of patients were eligible for chemotherapy before surgery, but only 19% of patients remained eligible postoperatively. Using a cut-off of 45 ml/min per 1.73 m², 80% of patients were eligible preoperatively, but only 55% remained eligible after surgery. This distribution persisted when we limited the analysis to patients with advanced pathologic stage (T3 or higher). Patients older than the median age of 70 yr were more likely to be ineligible for chemotherapy both pre- and postoperatively by either definition, and they were significantly more likely to have an eGFR <45 ml/min per 1.73 m² postoperatively, regardless of their starting eGFR. This study is limited by its retrospective nature, and there was some variability in the timing of postoperative serum creatinine measurements.

Conclusions

eGFR is significantly diminished after nephroureterectomy, particularly in elderly patients. These changes in renal function likely affect eligibility for adjuvant cisplatin-based therapy. Accordingly, we suggest strong consideration of neoadjuvant regimens.     

Randomised trial of blood transfusion versus a restrictive transfusion policy after hip fracture surgery

Background

Debate exists as to what should be the transfusion threshold for patients with anaemia after hip fracture surgery.

Methods

A total of 200 patients aged 60 years and above with a haemoglobin level of between 8.0 and 9.5 g dl⁻¹ after hip fracture surgery were randomised to receive a transfusion to raise the haemoglobin to at least 10.0 g dl⁻¹ or not to have a transfusion unless definite symptoms of anaemia became apparent. Patients were followed up for 1 year.

Results

There was no statistically significant difference in the outcomes of mortality, hospital stay, regain of mobility or complications between the two groups.

Conclusions

This study confirms other recent research studies which found that reducing the transfusion threshold to 8.0 g dl⁻¹ appears to be a safe practice for this group of patients.     

Postoperative opioid analgesic use after Nuss versus Ravitch pectus excavatum repair

Background/Purpose

Anticipated postoperative pain may affect procedure choice in patients with pectus excavatum. This study aims to compare postoperative pain in patients undergoing Nuss and Ravitch procedures.

Methods

A 5 year retrospective review was performed. Data on age, gender, Haller index, procedure, pain scores, pain medications, and length of hospital stay were collected. Total inpatient opioid administration was converted to morphine equivalent daily dose per kilogram (MEDD/kg) and compared between procedures.

Results

One hundred eighty-one patients underwent 125 (69%) Nuss and 56 (31%) Ravitch procedures. Ravitch patients were older (15.7 yo vs 14.6 yo, p = 0.004) and had a higher Haller index (5.21 vs 4.10, p = < 0.001). Nuss patients had higher average daily pain scores, received 25% more opioids (MEDD/kg 0.66 vs. 0.49, p = < 0.001), and received twice as much IV diazepam/kg. In the multivariate analysis, higher MEDD/kg correlated with both the Nuss procedure and older age in the Nuss group. Opioid administration did not correlate with Haller index or Nuss bar fixation technique. Increased NSAID administration did not correlate with lower use of opioids.

Conclusion

The Nuss procedure is associated with greater postoperative pain compared to the Ravitch procedure. Opioid use is higher in older patients undergoing the Nuss procedure, but is not associated with severity of deformity.     

Risk factors for persistent pain after urological surgery

Objective

Ten to 50% of patients with post-surgical pain develop chronic pain depending on the type of surgery. The objective of this study was to assess the incidence of persistent post-surgical pain (PPSP) and to identify risk factors following urology surgery.

Design

Retrospective observational study.

Patients

Two hundred and twenty-eight patients scheduled for urology surgery. Reasons for non-inclusions: patients who underwent a procedure not defined as being associated with PPSP.

Methods

Surgical urologic procedures potentially associated with PPSP were defined. All patients who had one of these procedures during the study period received a questionnaire by mail at least 3 months after the surgery. The files of these patients were retrospectively studied.

Results

Eight percent of the patients had preoperative pain. PPSP, assessed approximately 6 months after the surgery, was reported by 24% of the patients. Twenty-five (36%) of them reported neuropathic pain. Patients with PPSP had significantly more preoperative pain and an increased postoperative morphine consumption. Postoperative NSAID administration led to less persistent pain. Multivariate logistic regression analysis identified two independent risk factors of developing persistent pain: preoperative pain (OR = 21.6, 95% CI 6.7–69.5, P < 0.0001), morphine consumption 48 hours after surgery higher than 6 mg (OR = 2.3, 95% CI 1.2–4.3, P = 0.0118).

Conclusion

These findings confirm the role of preoperative pain and morphine consumption in the genesis of PPSP and call for establishing clinical perioperative pathways tailored to the patient.     

Influence of Preoperative and Postoperative Pelvic Floor Muscle Training (PFMT) Compared with Postoperative PFMT on Urinary Incontinence After Radical Prostatectomy: A Randomized Controlled Trial

Background

The efficacy of preoperative pelvic floor muscle training (PFMT) for urinary incontinence (UI) after open radical prostatectomy (ORP) and robot-assisted laparoscopic radical prostatectomy (RARP) is still unclear.

Objective

To determine whether patients with additional preoperative PFMT regain urinary continence earlier than patients with only postoperative PFMT after ORP and RARP.

Design, setting, and participants

A randomized controlled trial enrolled 180 men who planned to undergo ORP/RARP.

Intervention

The experimental group (E, n = 91) started PFMT 3 wk before surgery and continued after surgery. The control group (C, n = 89) started PFMT after catheter removal.

Outcome measurements and statistical analysis

The primary end point was time to continence. Patients measured urine loss daily (24-h pad test) until total continence (three consecutive days of 0 g of urine loss) was achieved. Secondary end points were 1-h pad test, visual analog scale (VAS), International Prostate Symptom Score (IPSS), and quality of life (King's Health Questionnaire [KHQ]). Kaplan-Meier analysis and Cox regression with correction for two strata (age and type of surgery) compared time and continence. The Fisher exact test was applied for the 1-h pad test and VAS; the Mann-Whitney U test was applied for IPSS and KHQ.

Results and limitations

Patients with additional preoperative PFMT had no shorter duration of postoperative UI compared with patients with only postoperative PFMT (p = 0.878). Median time to continence was 30 and 31 d, and median amount of first-day incontinence was 108 g and 124 g for groups E and C, respectively. Cox regression did not indicate a significant difference between groups E and C (p = 0.773; hazard ratio: 1.047 [0.768–1.425]). The 1-h pad test, VAS, and IPSS were comparable between both groups. However, “incontinence impact” (KHQ) was in favor of group E at 3 mo and 6 mo after surgery.

Conclusions

Three preoperative sessions of PFMT did not improve postoperative duration of incontinence.

Trial registration

Netherlands Trial Register No. NTR 1953.     

Oncologic Outcomes Following Three Different Approaches to the Distal Ureter and Bladder Cuff in Nephroureterectomy for Primary Upper Urinary Tract Urothelial Carcinoma

Background

There is a lack of consensus regarding the prognostic significance of different approaches to the bladder cuff at surgery for primary upper urinary tract urothelial carcinoma (UUT-UC).

Objectives

To compare the oncologic outcomes following radical nephroureterectomy using three different methods of managing the bladder cuff.

Design, setting, and participants

From January 1990 to December 2007, 414 patients with primary UUT-UC underwent radical nephroureterectomy at our institution. Of these, 301 were included in our study.

Intervention

Three methods of bladder cuff excision—intravesical incision, extravesical incision, and transurethral incision (TUI)—were performed.

Measurements

Patients’ medical records were reviewed retrospectively. The clinicopathologic data and oncologic outcomes were compared among groups.

Results and limitations

Of the 301 patients, 81 (26.9%) underwent the intravesical method, 129 (42.9%) underwent the extravesical technique, and 91 (30.2%) underwent TUI. There were no differences in clinical and histopathologic data among the three groups. When comparing the intravesical, extravesical, and TUI techniques, bladder recurrence developed in, respectively, 23.5%, 24.0%, and 17.6% cases (p = 0.485); local retroperitoneal recurrence in 7.4%, 7.8%, and 5.5% (p = 0.798); contralateral recurrence in 4.9%, 3.9%, and 2.2% (p = 0.632); and distant metastasis in 7.4%, 10.4%, and 5.5% (p = 0.564). There were no differences in recurrence-free and cancer-specific survival among the three groups (p = 0.680 and 0.502, respectively).

Conclusions

The three techniques had comparable oncologic outcomes. Our data validate the TUI method of bladder cuff control in patients with primary UUT-UC without coexistent bladder tumors.     

Radiological outcome and intraoperative evaluation of a computer-navigation system for femoral nailing: A retrospective cohort study

Aim

Intraoperative determinations of femoral antetorsion and leg length during fixation of femoral shaft fractures present a challenge. In femoral shaft fracture fixations, a computer-navigation system has shown promise in determining antetorsion and leg length discrepancies. This retrospective cohort study aimed to determine whether the use of computer navigation during femoral nailing procedures reduced postoperative femoral malrotation and leg length discrepancy, as well as the number of revision cases. We also sought to determine whether radiation exposure time was reduced when computer navigation was used.

Materials and methods

Of 246 patients treated for femoral shaft fractures between 2004 and 2012, we selected those that received postoperative computed tomography for rotation and leg length control. We included 24 patients who received navigation-assisted treatments and 48 who received unassisted treatments, matched for age, sex, and fracture type. All patients were treated by femoral nailing.

Results

The groups showed significant differences in the mean (standard deviation (SD) delay before surgery (navigation-assisted vs. unassisted groups: 8.5 ± 3.2 vs. 5.2 ± 5.8 days; P < 0.05) and surgery times (163.7 ± 43.94 vs. 98.3 ± 28.13 min; P < 0.001). The groups were significantly different in the mean (SD) radiation exposure time (4.43 ± 1.35 vs. 3.73 ± 1.5 min; P = 0.042), and were not significantly different in the postoperative femoral antetorsion difference (8.83 ± 5.52° vs. 12.4 ± 9.2°; P = 0.056), or in the postoperative length discrepancy (0.92 ± 0.75 vs. 0.95 ± 0.94 cm; P = 0.453). Four (16.7%) navigation-assisted and 15 (31.25%) unassisted surgeries got revision for torsion and/or length corrections.

Conclusion

Our results showed that, compared to unassisted femoral surgery, the computer-navigation system did not improve postoperative results or reduce radiation exposure. In the future, improvements in handling and application could facilitate the workflow and may provide better postoperative results. Currently, computer navigation may provide advantages for complicated or sophisticated cases, such as complex three-dimensional deformity corrections.

Level of evidence

Level III.     

Comparaison des valeurs de débit cardiaque obtenues à l’aide d’un nouveau système d’impédancemétrie thoracique avec les données du cathéter artériel pulmonaire en postopératoire de chirurgie cardiaque

Objective

Thoracic bioimpedance has been proposed for cardiac output (CO) determination and monitoring without calibration or thermodilution (ICG Monitor 862146, Philips Medical System, Philips, Suresnes, France). The accuracy and clinical applicability of this technology has not been fully evaluated in the cardiac surgery setting. We designed this prospective study to compare the accuracy of the ICG Monitor (CO_ICG) versus pulmonary artery catheter standard bolus thermodilution (CO_PAC) in patients after cardiac surgery or having benefited from cardiac surgery.

Study design

Prospective, monocentric.

Material and methods

We studied 13 patients in the postoperative period. CO_ICG and CO_PAC were determined at the arrival in the intensive care unit and every four hours. Bland-Altman and Critchley and Critchley's analysis were used to assess the agreement between CO_ICG and CO_PAC.

Results

CO_PAC ranged from 2.6 to 11.0 l/min and CO_ICG ranged from 1.8 to 11.7 l/min. There was a significant relationship between CO_PAC and CO_ICG (r = 0.61 ; p < 0.001). Agreement between CO_PAC and CO_ICG was −0.5 ± 1.3 l/min (Bland-Altman analysis). Percentage error between the two methods was 49% (Critchley and Critchley's analysis).

Conclusion

We found clinically unacceptable agreement between CO_ICG and CO_PAC in this setting. Despite its non invasiveness, this device cannot be recommended for CO monitoring in the postoperative period following cardiac surgery.     

Titration morphinique intraveineuse en salle de surveillance post-interventionnelle (SSPI) après chirurgie bariatrique sous cœlioscopie

Objective

There is limited information available regarding intravenous (IV) morphine admistration in obese patients in PACU. The aim of this study was to compare two IV morphine titration (IMT) regimen in two surgical centers.

Study design

Observational study.

Patients

Laparoscopic bariatric surgery in one private (Saint-Grégoire Clinic) and one public (University Hospital of Amiens) surgical center.

Methods

A strict and common protocol of IMT was implemented if PACU of both centers according to the recommendations of the French Society of Anaesthesia and Intensive Care. When pain score increased to > 30, IMT was titrated every 5 min in 3 mg increments until pain relief (VAS ≤30 mm). Pain level, dose of morphine (per total and ideal body weight), effectiveness, and side events were recorded.

Results

Data were recorded for 159 adult patients (129 women). Mean age and BMI were 42 ± 12 yrs and 43.8 ± 6.9 kg/m². Ninety-eight patients were eligible for IMT regimen but only 76 patients received IV morphine (47.8 %). Mean dose was 7.3 mg ± 3.5 mg [1–19 mg], (60.4 μg/kg and 115.8 μg/kg). IMT was less frequent, mean dose was greater (8.6 ± 4.2 vs 6.2 ± 2.9 mg) and number of patients with pain relief was higher (73.7 vs 35.6 %) in the public hospital. No severe adverse events have been recorded and there was no difference in both centers regarding these events.

Conclusion

Implementation of a IMT regimen in PACU was not associated with effective pain relief after laparoscopic surgery in obese patients.     

Procalcitonina y proteína C reactiva como marcadores precoces de infección intraabdominal postoperatoria en pacientes operados de cáncer gastrointestinal

Aim

to evaluate the association between serum levels of procalcitonin and C-reactive protein, on the first 3 postoperative days, and the appearance of postoperative intra-abdominal infection.

Method

Prospective observational study including 67 patients operated on for colo-rectal, gastric and pancreatic cancer. Serum levels of procalcitonin and C-reactive protein were analyzed before surgery and daily until the third postoperative day. Values of procalcitonin (PCT) and C-reactive protein (CRP) were recorded as well as their accuracy for detection of postoperative intra-abdominal infection (PIAI).

Results

The incidence of postoperative intra-abdominal infection was 13.4%. CRP serum levels at 72 h, PCT serum levels at 24, 48 and 72 h and the ratio between serum levels of CRP at 72 hours and serum levels of CRP at 48 hours (CRP D3/CRP D2) were significantly associated with the appearance of postoperative intra-abdominal infection. The highest sensitivity corresponded to PCT at 72 hours (88.9%); the highest specificity and positive predictive value corresponded to the ratio CRP D3/CRP D2 (96.49% and 71.4%, respectively); the highest negative predictive value to procalcitonin at 72 h and 24 h.

Conclusions

Serum levels of PCT are significantly associated with the appearance of postoperative intra-abdominal infection. Sensitivity and predictive positive values are low, but negative predictive value is high, even at 24 h after surgery.     

Effets de l’hydroxyzine sur l’acceptation du masque à l’induction de l’enfant

Objective

To evaluate the effectiveness of hydroxyzine as a premedication agent for the acceptance of facial mask during induction of general anaesthesia in children.

Study design

Prospective randomized single-blind study including ASA 1 and 2 children, aged between 1 and 9 years and undergoing outpatient surgery.

Patients and methods

Patients were randomly allocated to receive orally either 1 mg/kg hydroxyzine (G1) or water 0.1 ml/kg (G2) one hour before induction of standardized inhalational anaesthesia. Tolerance of facial mask was assessed with a 3-points scale (good, moderate or poor). Chi-square and Student's t-test were used in statistical analysis; p values less than 0.05 were considered statistically significant.

Results

One hundred patients were included (G1 = 49, G2 = 51). Demographic data were similar in both groups. Acceptance of facial mask was significantly better in G1 than in G2 (p = 0,002).

Conclusion

Hydroxyzine provided better acceptance of facial mask than placebo during induction of general anaesthesia in children.     

Bloc iliofascial et troubles cognitifs postopératoires chez la personne âgée

Objective

The aim of this study was to assess the influence of a regional analgesia technique on the incidence of postoperative cognitive dysfunction (POCD) after hip surgery, in elderly patients.

Patients and methods

Patients, aged over 65 years, were assigned in two groups according to the anaesthesia technique: group NKT (general anaesthesia with target concentration infusion of propofol and remifentanil, with a 0.1 mg/kg-bolus of morphine at the end of surgery), group KT (preoperative iliaca compartment block with catheter and then general anaesthesia without bolus of morphine). Postoperative analgesia was similar in both groups: paracetamol, tramadol, and subcutaneous morphine if verbal pain scale equal or greater than 2 (0.1 mg/kg). POCD was defined as a decrease in Mini Mental Status (MMSE) equal or greater than 2 points and was monitored during 2 days. Consumption of opioids, pain scores and side effects were recorded.

Results

Sixty-five patients were included: 34 in NKT group and 31 in KT group. MMSE scores were higher in the KT group at day1 and day2 (p = 0.01 and 0.0004, respectively). POCD was less frequent in group KT at day2 (6 % vs 41 % ; p = 0.001) and pain scores were lower during the first 48 hours (p = 0.03). Remifentanil consumption was lower in KT group (0.43 ± 0.18 mg vs 0.61 ± 0.25 mg, p = 0.002). Total amount of morphine, including the bolus in NKT group, was significantly lower in KT group (7 [5–17] mg vs 0 [0–5] mg, p < 10⁻⁶).

Conclusion

Postoperative analgesia by iliaca compartment block with catheter seems to provide a decrease in the incidence of POCD after hip surgery in elderly patients.

Study design

Prospective, observational study.     

Laparoscopic pancreaticojejunostomy for pancreatic ductal dilatation in children

Purpose

The application of laparoscopic surgery in pancreatic surgery in children is limited. In this article, we describe laparoscopic pancreaticojejunostomy for children with congenital pancreatic ductal dilatation.

Methods

Four children with recurrent pancreatitis and pancreatic ductal dilatation underwent laparoscopic pancreaticojejunostomy between July 2009 and November 2011. Longitudinal incision of the dilated pancreatic ducts and side-to-side Roux-Y pancreaticojejunostomy were performed.

Results

Operative time ranged from 103 to 154 min, and blood loss was minimal. The average postoperative hospital stay was 4 to 6 days. There were no pancreatic leaks. None of the patients experienced recurrence of pancreatitis.

Conclusions

Laparoscopic pancreaticojejunostomy for children with congenital pancreatic ductal dilatation is safe and effective.     

Anesthesia and postoperative analgesia after percutaneous hallux valgus repair in ambulatory patients

Background

Postoperative pain is often severe after hallux valgus repair. Sciatic nerve blocks with long-acting local anesthetics have been recommended for surgical anesthesia and postoperative analgesia. However, a novel percutaneous approach may require less analgesia and make the procedure suitable for ambulatory care. We thus tested the hypothesis that mid-foot block and sciatic nerve blocks provide comparable surgical anesthesia and postoperative analgesia, but that patients ambulate independently sooner after mid-foot block.

Study design

Prospective, randomized study.

Methods

Forty patients scheduled for ambulatory percutaneous hallux valgus repair were randomly assigned to two anesthesia and analgesia blocks: foot infiltration achieved by a mild foot block, or sciatic nerve block (30 mL of 7.5% ropivacaine for each block). Surgery was performed without sedation or additional analgesia. Both groups were given oral paracetamol/codeine and ketoprofene systematically; tramadol was added if necessary. Walking ability and pain scores were assessed for 48 postoperative hours.

Results

Demographic and morphometric characteristics, and duration of surgery were similar in each group. Pain scores were comparable and low in each group at rest and while walking. The time to ambulation without assistance was significantly less for patients in the infiltration group (3.8 ± 1.4 hours) than patients in the sciatic group (19.2 ± 9.5 hours; P < 0.0001).

Conclusion

After percutaneous hallux valgus repair, mid-foot block and sciatic nerve block provided comparable postoperative analgesia. However, mid-foot block seems preferable since the time to ambulation without assistance is much reduced.     

Laparoendoscopic Single-site Partial Nephrectomy Without Ischemia for Very Small,Exophytic Renal Masses: Surgical Details and Functional Outcomes

Background

Laparoendoscopic single-site surgery (LESS) has emerged as a natural progression from standard laparoscopy aiming to further minimize the morbidity of urologic procedures.

Objective

To describe our technique and report the surgical and functional outcomes of unclamped LESS partial nephrectomy (PN) in the treatment of small renal masses (SRMs).

Design, setting, and participants

Prospective evaluation of pre- and postoperative variables of patients undergoing the LESS-PN without ischemia between 2009 and 2012. The indications were single exophytic SRMs.

Surgical procedure

Unclamped LESS-PN was performed through a transperitoneal approach. A pararectal Hasson access technique was preferred. Single-port access was achieved via different single-port devices. A combination of straight and articulating laparoscopic instruments was used. The tumor was excised using bipolar scissors during normal renal perfusion. Hemostasis was achieved by bipolar electrocautery, parenchymal stitches, and hemostatic agents.

Outcome measurements and statistical analysis

Demographic, operative, postoperative, and pathologic outcomes data were recorded and analyzed.

Results and limitations

A total of 21 LESS-PN were performed (operative time: 111 ± 41 min; blood loss: 196 ± 195 ml: tumor size: 2.0 ± 0.3 cm). Neither conversion to open surgery nor transfusions occurred. Three patients required conversion to standard laparoscopy. Postoperatively, three complications (Clavien grades 2, 3a, and 4) were recorded. Pathologic examination revealed 14 clear cell carcinomas, four renal cysts, two oncocytomas, and one angiomyolipoma. Hospital stay was 4.4 ± 1.9 d. At the last follow-up (mean: 17 ± 11.5 mo), no port-site, local, or distant recurrences were detected. No significant variation in serum creatinine and estimated glomerular filtration rate was observed. Subjective scar evaluation indicated 66% of patients were very satisfied/enthusiastic. Study limitations include the small sample size, the lack of a control group, the short follow-up period, and the arbitrary measure of patient's scar perception.

Conclusions

Unclamped LESS-PN for selected SRMs is a safe and feasible procedure providing favorable postoperative outcomes and ensuring high levels of subjective, cosmetic satisfaction.     

The primary determinants of radiation use during fixation of proximal femur fractures

Objectives

To establish the primary determinants of operative radiation use during fixation of proximal femur fractures.

Design

Retrospective cohort study.

Setting

Level I trauma centre.

Cohort

205 patients treated surgically for subtrochanteric and intertrochanteric femoral fractures.

Main outcome measures

Fluoroscopy time, dose-area-product (DAP).

Results

Longer fluoroscopy time was correlated with higher body mass index (p = 0.04), subtrochanteric fracture (p < 0.001), attending surgeon (p = 0.001), and implant type (p < 0.001). Increased DAP was associated with higher body mass index (p < 0.001), subtrochanteric fracture (p = 0.002), attending surgeon (p = 0.003), lateral body position (p < 0.001), and implant type (p = 0.05).

Conclusion

The strongest determinants of radiation use during surgical fixation of intertrochanteric and subtrochanteric femur fractures were location of fracture, patient body position, patient body mass index, and the use of cephalomedullary devices. Surgeon style, presumably as it relates to teaching efforts, seems to strongly influence radiation use.