Laparoscopic surgery in children is associated with an intraoperative hypermetabolic response

Background Laparoscopic surgery is thought to be associated with a reduced metabolic response compared to open surgery. Oxygen consumption ( ) and energy metabolism during laparoscopic surgery have not been characterized in children. Methods We measured respiratory gas exchange intraoperatively in children undergoing 19 open and 20 laparoscopic procedures. Premature infants and patients with metabolic, renal, and cardiac abnormalities were excluded. Anesthesia was standardized. Unheated carbon dioxide was used for insufflation. was measured by indirect calorimetry. Core temperature was measured using an esophageal temperature probe. Results We found a steady increase in during laparoscopy. The increase in was more marked in younger children and was associated with a significant rise in core temperature. Open surgery was not associated with significant changes in core temperature or . Conclusions Laparoscopy in children is associated with an intraoperative hypermetabolic response characterized by increased oxygen consumption and core temperature. These changes are more marked in younger children. M. C. McHoney and L. Corizia contributed equally to the study, analysis, and writing of the paper     

Reliability of the Ely's test for assessing rectus femoris muscle flexibility and joint range of motion

Rehabilitative protocols and orthopadic research are significantly influenced by the ability to perform reliable measures of specific physical attributes or functions. The hypothesis was that the Ely's test for evaluating rectus femoris flexibility and joint range of motion (ROM) is a reliable clinical tool. Participants (n = 54) were between the ages of 18 and 45, and had no history of trauma. Three clinicians with orthopedic expertise assessed quadriceps flexibility and joint ROM using pass/fail and goniometer scoring systems. A retest session was completed 7 to 10 days later. Statistically, Kappa values for pass/fail scoring (intrarater , interrater ) and ICC values (intrarater , interrater ) for goniometer data both indicated that the Ely's test demonstrated only moderate levels of intra‐ and interrater reliability. Measurement error values (SEM = 4°, ME = 4°, and CV = 3%) and Bland and Altman plots (with 95% Limits of Agreement) further demonstrated the degree of intrarater variance for each examiner when executing the Ely's test in a clinical setting. Results call into question the statistical reliability of the Ely's test, and provide clinicians with important information regarding the reliability limits of the Ely's test when used to clinically evaluate flexibility and joint ROM in a physically active population. More research is required to determine the variables that may confound statistical reliability of this orthopedic technique that is commonly used in a clinical setting to assess function about the thigh region. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 26:793–799, 2008     

Cardiopulmonary Exercise Testing for Preoperative Risk Assessment before Pancreaticoduodenectomy for Cancer

Objective

Pancreaticoduodenectomy is the standard of care for tumors confined to the head of pancreas and can be undertaken with low operative mortality. The procedure has a high morbidity, particularly in older patient populations with preexisting comorbidities. This study evaluated the role of cardiopulmonary exercise testing to predict postoperative morbidity and outcome in high-risk patients undergoing pancreaticoduodenectomy.

Methods

In a prospective cohort of consecutive patients undergoing pancreaticoduodenectomy, those aged over 65 years (or younger with comorbidity) were categorized as high risk and underwent preoperative assessment by cardiopulmonary exercise testing (CPET) according to a predefined protocol. Data were collected on functional status, postoperative complications, and survival.

Results

A total of 143 patients underwent preoperative assessment, 50 of whom were deemed to be at low risk for surgery per study protocol. Of 93 high-risk patients, 64 proceeded to surgery after preoperative CPET. Neither anaerobic threshold (AT) nor maximal oxygen consumption ( $ \dot{V} $ o ₂ MAX) predicted patient mortality or morbidity. However, ventilatory equivalent of carbon dioxide ( $ \dot{V} $ e/ $ \dot{V} $ co ₂) at AT was a predictive marker of postoperative mortality, with an area under the curve (AUC) of 0.84 (95 % confidence interval [CI] 0.63–1.00, p = 0.020); a threshold of 41 was 75 % sensitive and 95 % specific (positive predictive value 50 %, negative predictive value 98 %). Above this threshold, raised $ \dot{V} $ e/ $ \dot{V} $ co ₂ predicted poor long-term survival (hazard ratio 2.05, 95 % CI 1.09–3.86, p = 0.026).

Conclusions

CPET is a useful adjunctive test for predicting postoperative outcome in patients being assessed for pancreaticoduodenectomy. Raised CPET-derived $ \dot{V} $ e/ $ \dot{V} $ co ₂ predicts early postoperative death and poor long-term survival.     

Early diastolic function during exertion influences exercise intolerance in patients with hypertrophic cardiomyopathy

Background

Hypertrophic cardiomyopathy (HCM) patients with preserved left ventricular ejection fraction (LVEF) often develop dyspnea and exercise intolerance. Diastolic dysfunction may contribute to exercise intolerance in these patients. This study aimed to clarify our hypothesis as to whether diastolic function rather than systolic function would be associated with exercise intolerance in HCM using two-dimensional (2D) speckle tracking echocardiography during exercise.

Methods

Thirty-three HCM patients (mean age 59.3 ± 15.7 years) underwent 2D speckle tracking echocardiography at rest and during submaximal semi-supine bicycle exercise. Global longitudinal strain (LS), LS rate during systole (LSRs), early diastole (LSRe), and late diastole (LSRa) were measured. The symptom-limited cardiopulmonary exercise testing was performed using a cycle ergometer for measuring the peak oxygen consumption (peak $ \dot{V}_{{{\text{O}}_{2} }} $ ).

Results

In the multivariate linear regression analysis, peak $ \dot{V}_{{{\text{O}}_{2} }} $ did not associate with strain or strain rate at rest. However, peak $ \dot{V}_{{{\text{O}}_{2} }} $ correlated with LS (β = ?0.403, p = 0.007), LSRe (β = 6.041, p = 0.001), and LSRa (β = 5.117, p = 0.021) during exercise after adjustment for age, gender, and heart rate. The first quartile peak $ \dot{V}_{{{\text{O}}_{2} }} $ (14.2 mL/min/kg) was assessed to predict exercise intolerance. The C-statistic of delta LSRe was 0.74, which was relatively greater than that of delta LS (0.70) and delta LSRa (0.58), indicating that early diastolic function rather than systolic and late diastolic function affects exercise intolerance.

Conclusions

LSRe during exercise is closely associated with the peak $ \dot{V}_{{{\text{O}}_{2} }} $ . Early diastolic function during exercise is an important determinant of exercise capacity in patients with HCM.     

Global longitudinal strain by two-dimensional speckle tracking imaging predicts exercise capacity in patients with chronic heart failure

Background

Left ventricular ejection fraction (LVEF) predicts mortality in patients with chronic heart failure (CHF). However, a weak correlation was found between LVEF and peak oxygen uptake ( $ \dot{V}{\text{O}}_{2} $ ) in CHF patients. Global longitudinal strain measured by two-dimensional (2D) strain is regarded as a more useful predictor of cardiac events than LVEF. We investigated whether 2D strain obtained at rest could predict peak $ \dot{V}{\text{O}}_{2} $ in patients with CHF.

Methods

Fifty-one patients (mean age of 54.0 ± 12.0 years, 14 females, LVEF 46.0 ± 15.0%) with stable CHF underwent resting echocardiography and cardiopulmonary exercise testing. Leg muscle strength was measured for the evaluation of peripheral factors. Global longitudinal strain (GLS) in the apical 4-, 3-, and 2-chamber views and global circumferential strain (GCS) in the parasternal mid short-axis view were measured.

Results

In all patients, peak $ \dot{V}{\text{O}}_{2} $ correlated with leg muscle strength (r = 0.55, p < 0.0001), LVEF (r = 0.46, p < 0.001), GLS (r = ?0.45, p < 0.001), and GCS (r = ?0.41, p = 0.005), respectively. No significant correlation was found between the ratio of early transmitral velocity to peak early diastolic mitral annulus velocity (E/E′) and peak $ \dot{V}{\text{O}}_{2} $ . In the patients with heart failure and reduced LVEF, a multiple stepwise linear regression analysis based on leg muscle strength, LVEF, E/E′, GLS, and GCS was performed to identify independent predictors of peak $ \dot{V}{\text{O}}_{2} $ , resulting in leg muscle strength and GLS (R ² = 0.888) as independent predictors of peak $ \dot{V}{\text{O}}_{2} $ .

Conclusion

Global longitudinal strain at rest could possibly predict exercise capacity, which appeared to be more useful than LVEF, E/E′, and GCS in CHF patients with reduced LVEF.     

Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for superobesity

Background:

Laparoscopic Roux‐en‐$\font\ss=cmss10 scaled 1000 \hbox{Y}$ gastric bypass (LRYGB) and laparoscopic biliopancreatic diversion with duodenal switch (LDS) are surgical options for superobesity. A randomized trial was conducted to evaluate perioperative (30‐day) safety and 1‐year results.

Methods:

Sixty patients with a body mass index (BMI) of 50–60 kg/m² were randomized to LRYGB or LDS. BMI, percentage of excess BMI lost, complications and readmissions were compared between groups.

Results:

Patient characteristics were similar in the two groups. Mean operating time was 91 min for LRYGB and 206 min for LDS (P < 0·001). One LDS was converted to open surgery. Early complications occurred in four patients undergoing LRYGB and seven having LDS (P = 0·327), with no deaths. Median stay was 2 days after LRYGB and 4 days after LDS (P < 0·001). Four and nine patients respectively had late complications (P = 0·121). Mean BMI at 1 year decreased from 54·8 to 38·5 kg/m² after LRYGB and from 55·2 to 32·5 kg/m² after LDS; percentage of excess BMI lost was greater after LDS (74·8 versus 54·4 per cent; P < 0·001).

Conclusion:

LRYGB and LDS can be performed with comparable perioperative safety in superobese patients. LDS provides greater weight loss in the first year. Registration number: NCT00327912 ( http://www.clinicaltrials.gov ). Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Local low‐dose lovastatin delivery improves the bone‐healing defect caused by Nf1 loss of function in osteoblasts

Postfracture tibial nonunion (pseudoarthrosis) leads to lifelong disability in patients with neurofibromatosis type I (NF1), a disorder caused by mutations in the NF1 gene. To determine the contribution of NF1 in bone healing, we assessed bone healing in the Nf1 conditional mouse model lacking Nf1 specifically in osteoblasts. A closed distal tibia fracture protocol and a longitudinal study design were used. During the 21‐ to 28‐day postfracture period, callus volume, as expected, decreased in wild‐type but not in Nf1 mice, suggesting delayed healing. At these two time points, bone volume (BV/TV) and volumetric bone mineral density (vBMD) measured by 3D micro–computed tomography were decreased in Nf1 callus‐bridging cortices and trabecular compartments compared with wild‐type controls. Histomorphometric analyses revealed the presence of cartilaginous remnants, a high amount of osteoid, and increased osteoclast surfaces in Nf1 calluses 21 days after fracture, which was accompanied by increased expression of osteopontin, Rankl, and Tgfβ. Callus strength measured by three‐point bending 28 days after fracture was reduced in Nf1 versus wild‐type calluses. Importantly, from a clinical point of view, this defect of callus maturation and strength could be ameliorated by local delivery of low‐dose lovastatin microparticles, which successfully decreased osteoid volume and cartilaginous remnant number and increased callus BV/TV and strength in mutant mice. These results thus indicate that the dysfunctions caused by loss of Nf1 in osteoblasts impair callus maturation and weaken callus mechanical properties and suggest that local delivery of low‐dose lovastatin may improve bone healing in NF1 patients. © 2010 American Society for Bone and Mineral Research     

Does appendix position affect the clinical outcome of acute appendicitis?

Objective: To elucidate if the course of acute appendicitis is influenced by the variable positions of the appendix. The appendix positions were divided into two groups: (i) the anterior group, which included the anterior, the pelvic and the paracaecal positions; and (ii) the posterior group, which included the retrocaecal and retroileal positions. Method: The hospital records of 161 patients who underwent appendectomy for acute appendicitis from January 2000 to June 2001 at Prince of Wales Hospital were reviewed retrospectively. Results: Clinicians’ delay in reaching the diagnosis was longer in the posterior group (9.9 h vs 5.8 h; P=0.043). However, complicated appendicitis (gangrenous changes, perforation or abscess formation) was not associated with the appendix location (P = 0.078). The median operating time for laparoscopic appendectomies lasted longer in the posterior group (77.5 min vs 60 min; P = 0.02). These patients also had a longer hospital stay (6 days vs 4 days; P = 0.049). No difference was observed among patients who underwent open surgery. Conclusion: Appendices in the ‘hidden’ position did not translate into a higher incidence of complicated appendicitis or postoperative complications except for the slightly longer hospital stay in patients treated by laparoscopy. Therefore, we concluded that the location of appendices does not affect the clinical course of appendicitis in the locality studied.      

A rare cause of gastrointestinal bleeding: Blue rubber bleb nevus syndrome

A 33‐year‐old Chinese female patient with blue rubber bleb nevus syndrome presenting with anaemia and fresh per‐rectal bleeding is reported. This is a rare disease, but the associated distinctive cutaneous haemangiomas should alert every clinician of the diagnosis. The clinical presentation, investigation and management of this rare syndrome is discussed.      

Transposition of the posterior tibial tendon in spastic equinovarus

Summary Eleven posterior tibial tendon transfers were performed in eight patients with spastic equinovarus with an average follow-up of 3 years (range years). The main goals—to eliminate the need for braces and to improve gait—were achieved in all patients. An adequate operation technique kept the well-known postoperative complications, e.g., valgus and calcaneal deformity, to a minimum.

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Zusammenfassung Die Transposition der Musc. tibialis posterior-Sehne als operative Behandlung des spastischen Equinovarus wurde elfmal durchgeführt bei acht Patienten. Die Ergebnisse wurden Jahre nach der Operation kontrolliert. Das Hauptziel: Unabhängigkeit von Orthesen and Verbesserung der Gehfähigkeit, konnte bei allen Patienten erreicht werden. Eine adequate Operationstechnik konnte die bekannten postoperativen Komplikationen, wie eine Valgus- und Hackenfuß-Deformität bis auf ein Minimum beschränken.

     

Gastric emptying scintigraphy in carcinoma of the pancreas

Objective: In patients with unresectable carcinoma of the pancreas, the role of prophylactic gastroenterostomy is debatable. Many workers still recommend combined biliary and enteric bypass at the initial surgery despite known complications of gastroenterostomy. Method: We conducted a prospective study in 17 patients with carcinoma of the pancreas without mechanical obstruction, to evaluate the presence of functional gastroparesis by doing a radionuclide, solid‐phase scintigraphy. We tried to correlate delayed gastric emptying (DGE) with symptoms of gastric outlet obstruction, serum bilirubin level, stage of disease and intraoperative assessment. Results: Of the 17 patients, seven (41.2%) had DGE. No correlation was found between delayed emptying and symptoms, serum bilirubin level, stage of disease or intraoperative assessment for gastric outlet obstruction. Conclusion: Solid‐phase gastric emptying scintigraphy may help to detect DGE in patients with carcinoma of the pancreas preoperatively. Patients with DGE may be chosen for prophylactic gastrojejunostomy during the initial biliary bypass.      

Laparoscopic cholecystectomy in haemodialysis patients

Objective : To study the effect and safety of laparoscopic cholecystectomy in haemodialysis patients. Method : From May 1994 to December 1998, the clinical progress of nine haemodialysis patients who underwent laparoscopic cholecystectomy were reviewed. Results : Eight patients recovered very well from surgery, while one patient had a mild complication of a collection of seroma represented by ultrasound in the gallbladder region. Conclusions : Perioperative management is important when performing laparoscopic cholecystectomy in patients on haemodialysis. Those patients on well‐managed haemodialysis will tolerate laparoscopic cholecystectomy.      

An analysis of CO2 elimination curves during artificial ventilation

We have developed some indices to evaluate the phase III slope in CO₂ elimination curves. The indices were applied to 12 mechanically ventilated patients in ICU to determine their stability under various ventilator settings. F_co2-sl[30–90] and expressed the mean incline of phase III slope in F_co2-volume curves and -volume curves, respectively. F_co2-SR and -SR expressed the ratio of the slopes in the first and second halves of the phase III portion in both curves. The indices were also applied to 108 elective surgery patients to determine their usefulness in predicting ventilatory efficiency during general anesthesia. In the first study, F_co2-sl[30–90] and [30–90] correlated with ET_co2, V_d/V_t and the volume of CO₂ expired, but F_co2-SR and -SR were independent of these parameters. -SR did not show any significant changes under various ventilator settings except for application of PEEP. In the second study, those with impaired preoperative respiratory function had significantly larger values for . was as sensitive as parameters such as V_D/V_T, arterial to end-tidal CO₂ tension difference (a-ET·D_co2), and volume pressure index (VPI) in prediting poor respiratory functions. We concluded that is a useful index for evaluating the phase III slope in CO₂ elimination curves.     

Clinical outcome of patients with initial diagnosis of acute self‐limiting colitis of unknown aetiology

Objective : To investigate the clinical course and outcome of patients whose initial histological features were compatible with acute self‐limiting colitis (ASLC) of unknown aetiology. Materials and Methods : We performed a computer search of our pathology registry for non‐specific inflammation of the colon and rectum for the years 1997–98. The histology reports and clinical notes were reviewed in detail. Results : Thirty‐three suitable patients were identified (17 males) with a median age of 48 years (22–87 years). The commonest presenting symptoms were rectal bleeding and diarrhoea. The passage of mucus and abdominal pain were also commonly found symptoms. Physical examination was usually normal, although abdominal tenderness was occasionally elicited. Systemic upset was unusual. Three patients had complications at presentation: severe bleeding (n = 1), intestinal obstruction (probably unrelated, n = 1), sigmoid colon cancer (probably unrelated, n = 1). Of 30 patients who were observed only, 10 patients’ symptoms resolved and 8 patients improved symptomatically, one worsened and one had not returned for reassessment. Ten subsequently needed medical treatment. Together with the other 3, a total of 13 patients received medication at some stage in their disease and 3 patients eventually required long‐term therapy. Two patients developed ulcerative colitis after 7.5 and 12 years, respectively. Conclusion : Patients with initial histological features of ASLC usually follow a self‐limiting clinical course and an initial period of observation is justified. Progression to a more protracted disease course occurs in one‐third and the diagnosis of ASLC should be revised. Salicylates and steroids are useful in refractory cases. Less than 6% progressed to chronic inflammatory bowel disease.      

Creation of a subcutaneous tunnel in antesternal oesophageal replacement with the aid of a rigid sigmoidoscope

A technique to create a subcutaneous tunnel in antesternal oesophageal replacement using a rigid sigmoidoscope is reported.      

Laparoscopic appendectomy in young female patients: Should we remove the normal-looking appendix?

Objective : This study evaluated whether a significant reduction in unnecessary appendectomies is possible by performing diagnostic laparoscopy before appendectomy in female patients of child-bearing age, leaving behind the normal-looking appendix. Materials and methods : Sixty-one consecutive female patients between the ages of 15 and 45 years with clinical diagnosis of acute appendicitis were studied prospectively. Diagnostic laparoscopy was performed to detect whether the appendix was inflamed. The appendix was then removed and the result of laparoscopic diagnosis was matched with histological diagnosis. Results : Ten out of the 42 laparoscopically diagnosed appendicitis cases had normal appendices on histological examination. Six out of the 19 laparoscopically diagnosed normal appendices had histological evidence of appendicitis. The sensitivity of laparoscopy was 84% and the specificity was 56.5%. Conclusions : Discrepancies existed between laparoscopic appearance and histological examination in acute appendicitis. The appendices of all those with clinically suspected appendicitis should be removed and sent for histological confirmation.      

Annual Scientific Meeting of The College of Surgeons of Hong Kong: A 5‐year audit

Objective : To examine the quality of surgical research in Hong Kong by auditing the results of abstracts submitted for annual scientific meetings held by The College of Surgeons of Hong Kong. Materials and Methods : From 1993 to 1998, all abstracts submitted for the meetings were evaluated and classified according to the hierarchy of evidence. The institutions of the presenting authors were recorded. Ovid MEDLINE search was then conducted to determine whether the abstracts were subsequently published in an indexed medical journal. Results : In total, 165 abstracts were submitted for the meeting in a 5‐year period. Randomized controlled trials constituted 12% of this research. Participation from community surgeons showed an encouraging trend from 17% in 1993 to 63% in 1998. In the first 4 years, 38% of abstracts were of publishable quality. More than half of the prospective randomized controlled trials were selected for presentation and subsequently published. Those abstracts selected for presentation have a higher chance of being published subsequently (P < 0.03). Conclusions : The randomized controlled trial remains a powerful research tool but is scarce in Hong Kong surgical research.      

Evaluation of Hyphecan (1‐4,2‐acetamide‐deoxy‐B‐D‐glucan polymer) on wound healing in a rodent model

Objective: To evaluate the effect of an artificial skin Hyphecan (1‐4,2‐acetamide‐deoxy‐B ‐D ‐glucan polymer) on wound healing in a rodent model. Materials and Method: The prospective study was conducted at a basic science laboratory at a tertiary teaching hospital. Two 4 cm × 4 cm full‐thickness wounds were created on the dorsal surface of 10 Spraque–Dawley rats and covered with Hyphecan and Kaltostat, respectively. Wounds were examined and measured on days 4, 10, 21 and 28, and would continue after day 28 until healed up completely. Punch biopsies (3 mm) were taken on days 4, 10 and 28 for histological examination of the response of healing and repair. Results: Despite the fact that the wound healing rate was similar for both groups on days 4, 10, 21 and 28, the average healing time for the Hyphecan group (29.1 ± 1.7 days) was significantly shorter statistically (P = 0.03) than the Kaltostat group (30.7 ± 2.8 days). Conversely, the marked healing response elicited by Hyphecan on day 4 persisted on days 10 and 28 in contrast to Kaltostat, which had only a mild degree of healing response on days 10 and 28. The study suggests that wounds treated by Hyphecan heal faster than Kaltostat. Conclusion: The findings provide basic scientific evidence supporting the clinical use of Hyphecan in different wounds and might also reduce the cost of wound management as Hyphecan is cheaper than Kaltostat and requires a shorter treatment time.      

Efficacy of ciprofloxacin in urinary tract infections and risk factors for ciprofloxacin-resistant infections

Objectives : The study was undertaken to assess the safety and efficacy of sequential intravenous and oral ciprofloxacin in the treatment of moderate-to-severe urinary tract infections (UTI), and to identify risk factors for acquiring UTI caused by ciprofloxacin-resistant organisms. Materials and Methods : Using a prospective, open, single-centre study design, hospitalized patients with a clinical diagnosis of moderately severe UTI were enrolled. After a minimum of 3 days of intravenous ciprofloxacin, patients were switched to oral therapy. Assessment for response and analysis of risk factors were performed at the end of therapy. Results : Between December 1996 and November 1997, a total of 66 patients met the criteria for efficacy evaluation. Among the 55 patients with ciprofloxacin-sensitive organisms, 51 patients (93%) were cured. Persisting infection was noted in three patients (5%) and one patient (2%) was re-infected with a ciprofloxacin-resistant organism. Of the organisms isolated, 14 (19%) were resistant to ciprofloxacin. The presence of prostatic obstruction (odds ratio 6.02, 95% confidence interval (CI) 1.28–28.30, P = 0.02) and recurrent UTI (odds ratio 8.63, 95% CI 1.81–41.17, P = 0.007) were independently associated with infections caused by ciprofloxacin-resistant organisms. Adverse events were reported in 5 patients (8%) but no premature discontinuation or mortality was documented. Conclusion : Sequential therapy with oral therapy after initial parenteral ciprofloxacin is safe and effective in the management of moderate-to-severe UTI in appropriately selected patients.      

Irreducible inguinal hernia: To reduce or not to reduce?

A case of irreducible inguinal hernia is reported. Successful reduction of the hernia resulted in delayed perforation of the sigmoid colon and faecal peritonitis. The question of whether one should attempt reducing an irreducible inguinal hernia is discussed.