Care burden and outcome of the surgical management of ulcerative colitis: A retrospective analysis of the last 20 years in a tertiary hospital in Spain

AimTo analyze the surgical burden of UC care in the last two decades, analyzing the characteristics of the patients, surgical indications along with the short and long-term results.MethodSingle-center retrospective cohort analysis of UC patients undergoing abdominal and anorectal surgery between January 2000 and December 2020. The care burden, clinical data and results were analyzed according to distribution by decades.Results128 patients, 37% female, underwent 376 surgical interventions (296 intestinal procedures and 80 anorectal). Mean follow-up for the cohort was 106 ± 64 months. Timing from diagnosis to first surgery was under 5 years in 53.3%. In the second decade of the study there were fewer operated patients (73 vs. 48) as well as the total number of interventions per patient (2.7 vs. 2.0). The proportion between elective and urgent surgery was reversed in the second decade, observing an increase in laparoscopic surgery (70% vs. 8%) together with a decrease in major postoperative morbidity (Clavien-Dindo ≥ IIIa) (20% vs 8.4%). 80 patients underwent a restorative proctocolectomy, with a failure of 5% at 1 year but 23.7% in the long term. 37 patients required anorectal surgery, of which 26 (71%) were serial interventions, most due to septic complications of the pouches.ConclusionsThe number of colectomies and interventions per patient decreased in the last decade, while there were improvements in morbidity and surgical approach. The need for sequential surgeries and long-term active instrumental surveillance for possible functional deterioration constitutes a significant clinical burden.     

Embolización vesical supraselectiva versus formalina intravesical para la hematuria intratable en pacientes con cáncer de vejiga

ObjectiveIntractable hematuria is a leading critical problem occurring in patients with advanced stage bladder cancer (BCa) that are not suitable for radical cystectomy. The present study, for the first time in the literature, aimed to compare the effectiveness of intravesical formalin (IF) and superselective vesical artery embolization (SVAE) in the management of intractable and life-threatening hematuria in BCa patients.MethodsThe retrospective study included 40 BCa patients who underwent SVAE or IF treatment due to intractable hematuria after failure of other methods. Patients were divided into two groups based on the procedures administered: SVEA Group (n = 24) and IF Group (n = 16).ResultsThe success rate at first-line therapy was 50% (12/24) in SVAE Group and 82% (13/16) in IF Group (p = 0.046). Based on the success rates at first- and second-line therapies, the overall success rate in SVAE Group was 75% and this rate was similar to that of IF Group (p = 0.439). Complication rate was significantly higher in IF patients than in SVAE patients (37.5% vs. 8.3; p = 0.024), whereas duration of postoperative hospital stay was significantly longer in SVAE Group (15.8 vs. 6 days; p = 0.041).ConclusionThe advantages of IF appear to include shorter postoperative hospital stays and higher success rates at a single session, while the advantages of SVAE seem to include non-requirement of spinal/general anesthesia, easy repeatability, and low complication rates. In the management of patients with intractable hematuria, patients’ general condition, comorbidities, and anesthesia-related risks should be taken into consideration.     

Effect of Postoperative Restrictive Fluid Therapy in the Recovery of Patients with Abdominal Vascular Surgery

ObjectiveTo compare the outcome of the postoperative administration of a restricted or standard intravenous fluid regimen in patients who underwent elective abdominal vascular surgery. The primary end point was postoperative hospital stay.DesignProspective observer-blinded, randomised controlled trial.Material and methodsPatients were considered eligible if they underwent transperitoneal aorto-iliac approach with infrarenal graft repair. During the operation and intensive care unit stay, fluids were prescribed by the anaesthetists who were unaware of the details of the study. In the vascular surgical ward, patients in the standard group (SG) received 2500 ml of fluids per day, whereas patients in the restricted group (RG) received 1500 ml of fluids per day. All the patients were evaluated on an intention-to-treat basis.ResultsForty patients were randomised to the RG (n = 20) or SG (n = 20). No significant differences were observed in the recovery of gastrointestinal function. However, the postoperative hospital stay was shorter in the RG (8 days) than in the SG (12 days) (p = 0.003).ConclusionsThe use of a restrictive postoperative fluid protocol significantly reduces the duration of hospital stay in patients who have undergone major elective abdominal vascular surgery.     

Thoracoscopic surgery in the prone position for esophageal cancer in patients with situs inversus totalis: A report of two cases

IntroductionSitus inversus totalis (SIT) is a rare congenital condition characterized by a complete transposition of thoracic and abdominal organs. Here, we present two successful cases of left thoracoscopic esophagectomy in the prone position for SIT-associated esophageal cancer.Presentation of caseOur first case was of an 82-year-old man who underwent a left thoracoscopic esophagectomy in the prone position, followed by hand-assisted laparoscopic gastric mobilization. Surgical duration and blood loss were 661 min and 165 g, respectively. His postoperative course was uneventful. The second case was of a 66-year-old man who underwent a left thoracoscopic esophagectomy in the prone position, followed by gastric mobilization via laparotomy owing to a concomitant intestinal malrotation and polysplenia. Surgical duration and blood loss were 637 min and 220 g, respectively. We trained for the surgical procedures preoperatively using left-inverted and right-inverted thoracoscopic surgical videos of patients with normal anatomy.DiscussionSurgical procedures in SIT patients are challenging owing to their mirrored anatomy. Recognition of their variations is thus important to avoid intraoperative accidental injuries. Left-inverted and right-inverted thoracoscopic surgical videos of patients with normal anatomy were found to be useful for image training prior to the actual surgery.ConclusionThoracoscopic surgical treatment for esophageal cancer associated with SIT in the prone position can be performed safely, similar to the manner performed for thoracoscopic surgery in the right decubitus position, or surgery via an open thoracotomy. Gastric mobilization via laparotomy should be considered in patients associated other anatomic variations.     

Single-stage versus multi-stage pull-through for Hirschsprung's disease: Practice trends and outcomes in infants

PurposeThe aim of this study was to evaluate surgical treatments and outcomes in a multi-institutional cohort of neonates with Hirschsprung's disease (HD).MethodsUsing the Pediatric Health Information System (PHIS) from 1999 to 2009, neonates diagnosed with HD were identified and classified as having a single stage pull-through (SSPT) or multi-stage pull-through (MSPT). Diagnosis and classification algorithms and clinical variables and outcomes were validated by multi-institutional chart review. Groups were compared using logistic regression modeling and propensity-score matched analysis to account for baseline differences between groups.Results1555 neonates with HD were identified; 77.2% underwent SSPT and 22.8% underwent MSPT. Misclassification of disease or surgical treatment was < 2%. Rates of SSPT increased over time (p = 0.03). Compared to SSPT, patients undergoing MSPT had significantly lower birth weights and higher rates of prematurity, non-HD gastrointestinal anomalies, enterocolitis, and preoperative mechanical ventilation. Patients undergoing MSPT had significantly higher rates of readmissions (58.5 vs. 37.9%) and additional operations (38.7 vs. 26%). Results were consistent in the propensity-score matched analysis.ConclusionMost neonates with HD undergo SSPT. In patients with similar observed baseline characteristics, MSPT was associated with worse outcomes suggesting that some infants currently selected to undergo MSPT may have better outcomes with SSPT. However, there remains a subgroup of MSPT patients who were too ill to be adequately compared to SSPT patients; for this subgroup of severely ill infants with HD, MSPT may be the best option.     

Outcomes of percutaneous nephrolithotomy versus open stone surgery for patients with staghorn calculi

ObjectivesAdvances in shock wave lithotripsy and endourological procedures have markedly limited the need for open surgery in the treatment of renal stones. We retrospectively compared the clinical outcomes of percutaneous nephrolithotomy (PNL)-based therapy with open stone surgery (OSS) to treat staghorn stones.Materials and methodsHospital and office charts, operative records, and radiographic studies of all patients undergoing OSS (Group 1, 11 patients) and PNL (Group 2, 61 patients) for the treatment of large staghorn calculi from 2007 to 2013 were reviewed. Only patients with stones ≥ 10 cm² in area were included. Patient characteristics, stone burden, indications, and surgical outcomes between the two procedures were compared. Stone-clearance was confirmed using postoperative kidney, ureter, bladder X-rays.ResultsThere were no differences between the two groups in patient demographics, stone size, estimated blood loss, and mean renal function level change, however, there were statistically significant differences in mean operative time (282.1 ± 54.5 minutes vs. 156.6 ± 41.2 minutes, p < 0.001), mean hospital stay (10.3 ± 1.8 days vs. 6.2 ± 2.7 days, p < 0.001), postoperative stone-clearance rate (97.5% vs. 76.1 ± 23.9%, p < 0.001), and number of procedures per patient (1.6 vs. 2.8, p < 0.001) between the OSS and PNL group.ConclusionBoth OSS and PNL are viable options for the management of staghorn stones. Considering the lower postoperative complication rate and need for auxiliary treatment, we suggest that OSS is more suitable for staghorn stones with large burdens. OSS should still be considered as a valid treatment for patients with complex staghorn calculi, although PNL is a less invasive treatment option in most cases.     

Balloon Angioplasty as the Primary Treatment for Failing Infra-inguinal Vein Grafts

BackgroundWe sought to evaluate the role of balloon angioplasty as the primary modality in the management of vein graft stenoses.MethodsPatients who underwent infrainguinal vein graft bypass from January 2002 to December 2007 were enrolled into a surveillance program. Grafts which developed critical stenoses were identified and underwent urgent angiography with a view to angioplasty of the stenotic lesion. Lesions which were deemed unsuitable for angioplasty underwent urgent surgical repair.ResultsFour hundred and eleven grafts were followed up for a median of 19 months (range: 2–61). Ninety-six grafts (22.6%) developed critical stenosis. Twelve grafts occluded prior to repair and one was not intervened upon electively. Eight grafts underwent primary surgical repair. Seventy-six grafts underwent 99 endovascular procedures. Technical success was achieved in 60 grafts (78.9%). Of the grafts in which technical success had not been achieved, eight underwent repeat angioplasty and three were surgically repaired. Twenty-four grafts underwent repeat angioplasty for re-stenosis with a technical success rate of 71%. No difference was observed in graft patency (P = 0.08) or amputation rates (P = 0.32) between the grafts requiring intervention to maintain patency, and grafts which did not. Smoking [OR: 2.61 (95% CI: 1.51–4.53), (P = 0.006)], diabetes [OR: 2.55 (95% CI: 1.49–4.35), (P = 0.006)], renal failure [OR: 1.89 (95% CI: 1.19–3.38), (P = 0.040)] and recurrent stenosis [OR: 3.22 (95% CI: 1.63–4.69), (P < 0.001)] were risk factors for graft occlusion.ConclusionsBalloon angioplasty of failing infrainguinal vein bypass grafts is safe and can be performed with an acceptable medium term patency rate, albeit with a significant risk of re-stenosis which can be successfully treated in most patients using repeat endovascular intervention.     

Estudio comparativo entre cirugía retrógrada intrarrenal y micro-nefrolitotomía percutánea en el tratamiento de la litiasis renal de tamaño intermedio

ObjectiveRetrograde intrarenal surgery (RIRS) has proven efficacy with minimal morbidity in the treatment of intermediate-sized kidney stones. The aim of this study was to examine the feasibility of micropercutaneous nephrolithotomy (microperc) for this indication and evaluate its results compared with those of RIRS.Material and methodsFrom September to December 2013, we performed a comparative prospective study between RIRS and microperc, with 20 consecutive patients with intermediate-sized (1–3 cm) kidney stones. We employed a flexible dual-channel ureteroscope (Cobra, Richard Wolf GmbH) and a Microperc 4.85/8 Fr (with the patient supine) with flexible fiberoptics (0.9 mm, 120° and 10,000 pixels) (PolyDiagnost GmbH). The study variables were demographic data, stone characteristics, percentage of stone elimination, complications (Clavien-Dindo), surgical time, hospital stay and need for auxiliary procedures.ResultsThe patients underwent RIRS (n = 12) or microperc (n = 8). There were no differences in the demographics or stone characteristics between the 2 groups. The percentage of stone elimination with RIRS and microperc was 91.7% and 87.5% (P = 1), respectively. One of the patients who underwent RIRS (8.3%) experienced postoperative fever; one of the patients who underwent microperc (12.5%) experienced postoperative colic pain (both cases were classified as Clavien I). The operative times were similar: 120 min (111.2–148.7) and 120 (88.7–167.5) min for RIRS and microperc (P = .8), respectively. None of the patients required a blood transfusion. The hospital stays were also equivalent: 1 day (1–2) and 1.5 days (1–3.5) for RIRS and microperc (P = .33), respectively. Two patients treated with microperc (25%) required auxiliary procedures (simultaneous RIRS and flexible nephroscopy after percutaneous trajectory dilation to treat, in both cases, a significant fragment that had migrated to an inaccessible calyx), and 1 patient in the RIRS group (8.3%) required percutaneous nephrolithotomy due to unfavorable infundibular-calyceal anatomy (P = .54).ConclusionsMicroperc is a minimally invasive method that is emerging as an effective and safe treatment for intermediate-sized kidney stones. Studies are needed to better evaluate its cost-effectiveness, the need for complementary treatments and its possible complementarity with RIRS when working with patients in the supine position.     

Hybrid treatment combining emergency surgery and intraoperative interventional radiology for severe trauma

ObjectTo evaluate the efficacy of hybrid treatment combining emergency surgery and intraoperative interventional radiology (IVR) for severe trauma.Patients and methodsThe records of 63 severely injured patients who underwent concurrent emergency surgery and IVR at our emergency centre from 1999 through 2013 were retrospectively reviewed. Mobile digital subtraction angiography device was used in the operating room when performing IVR. Patients undergoing hybrid treatment combining intraoperative IVR and emergency surgery (intraoperative IVR group) were compared with those undergoing IVR in the angiography suite before or after emergency surgery (control group).ResultsThirteen patients underwent hybrid treatment (intraoperative IVR group). Of these 13 patients, 7 underwent treatment for abdominal organ injuries, and 6 for multiregional injuries. Emergency operations were laparotomy (n = 12), thoracotomy (n = 1), craniotomy (n = 1), and haemostasis of the lower extremities (n = 1). Five patients underwent damage control surgery. IVR included transarterial embolisation (n = 12), endovascular stent or stent-graft placement (n = 2), and embolisation of a portal vein by laparotomy (n = 2). The mean ISS was 40. The actual overall survival rate was 85%, and the probability of survival (Ps) was 62%. The control group included 45 patients. Five patients who met exclusion criteria were not included in the control group. Age, ISS, RTS, Ps, pH and base excess on arrival, and blood transfusion volume during operation and IVR did not differ significantly between the groups. Total time during operation and IVR was significantly shorter in the intraoperative IVR group than in the control group (229 [SD 72] min vs. 355 [SD 169] min; p = 0.007). The mortality were 15 (95% CI 2–45) % in the intraoperative IVR group vs. 36 (95% CI 22–51) % in the control group.ConclusionHybrid treatment combining emergency surgery and intraoperative IVR can be a novel treatment strategy for severe trauma, and it will improve patient outcomes due to reduction of the time for resuscitation.     

Posición óptima para la nefrolitotomía percutánea en el riñón en herradura: ¿prono tradicional o supino?

ObjectiveAlthough it was stated that supine percutaneous nephrolithotomy (PCNL) was associated with relatively shorter surgical times and comparable success and complication rates, there is no consensus in the current literature concerning the safety and efficacy of supine PCNL in patients with horseshoe kidneys. We aimed to compare supine and prone PCNL regarding safety and efficacy in patients with horseshoe kidneys.MethodsData of the patients with horseshoe kidneys who underwent PCNL for renal stones larger than 2 cm between January 2010 and May 2021 were retrospectively reviewed. The study patients were categorized as Group 1 (i.e., supine PCNL-SPCNL) and Group 2 (i.e., prone PCNL-PPCNL). Both groups were compared regarding demographic, clinical, and surgical data.ResultsSixty-five patients were included. Among these patients, 31 (47.7%) were in Group 1, while 34 (52.3%) were in Group 2. Both groups were statistically similar in terms of demographic data, stone characteristics, perioperative parameters, and complication rates (P > .05). There was no statistical difference in terms of additional treatment rates, stone-free rates in the postoperative second-day and third-month evaluations (P > .05). Mean surgical time was significantly longer in Group 2 (113 ± 17.1 minutes) than in Group 1 (90.6 ± 11.3 minutes) (P = .000).ConclusionAlthough it is traditionally performed in the prone position, the supine approach is as safe and effective as the prone approach. In addition, the supine approach is associated with significantly shorter surgical times.     

Sugammadex versus neostigmina em pacientes pediátricos: estudo prospectivo e randomizado

Background and objectivesAcetylcholinesterase inhibitors may cause postoperative residual curarization when they are used for reversal of neuromuscular blockade. Sugammadex reverses neuromuscular blockade by chemical encapsulation and is not associated with the side effects that may occur with the use of anticholinesterase agents. Because of increased outpatient surgical procedures postoperative residual curarization and rapid postoperative recovery have a greater importance in the pediatric patient population. The aim of this study was to compare the efficacy of sugammadex and neostigmine on reversing neuromuscular blockade in pediatric patients undergoing outpatient surgical procedures.Methods80 patients, aged 2–12 years, scheduled for outpatient surgery were enrolled in this randomized prospective study. Neuromuscular blockade was achieved with 0.6 mg kg⁻¹ rocuronium and monitorized with train‐of‐four. Group RN (n = 40) received 0.03 mg kg⁻¹ neostigmine, Group RS (n = 40) received 2 mg kg⁻¹ sugammadex for reversal of rocuronium. Extubation time (time from the reversal of neuromuscular blockade to extubation), train‐of‐four ratio during this time, time to reach train‐of‐four > 0.9, and probable complications were recorded.ResultsThere was no significant difference between the patients’ characteristics. Extubation time and time to reach train‐of‐four > 0.9 were significantly higher in Group RN (p = 0.001, p = 0.002). Train‐of‐four at the time of neostigmine/sugammadex injection in Group RN were significantly higher than in the RS group (p = 0.020). Extubation train‐of‐four ratio was significantly lower in Group RN (p = 0.002).ConclusionSugammadex provides safer extubation with a shorter recovery time than neostigmine in pediatric patients undergoing outpatient surgical procedures.     

Estudio multicéntrico de costes de 2 técnicas quirúrgicas: láser GreenLight XPS 180 W vs resección transuretral de la próstata

ObjectiveTo analyze the costs associated with two surgical procedures for lower urinary tract symptoms secondary to benign prostatic hyperplasia: GreenLight XPS 180¦W versus the gold standard transurethral resection of the prostate.MethodsA multicenter, retrospective cost study was carried out from the National Health Service perspective, over a 3-month time period. Costs were broken down into pre-surgical, surgical and post-surgical phases. Data were extracted from records of patients operated sequentially, with IPSS = 15, Qmax = 15 mL/seg and a prostate volume of 40-80 mL, adding only direct healthcare costs (€, 2013) associated with the procedure and management of complications.ResultsA total of 79 patients sequentially underwent GL XPS (n: 39) or TURP (n: 40) between July and October, 2013. Clinical outcomes were similar (94.9% and 92.5%, GL XPS and TURP, respectively) without significant differences (P = .67). The average direct cost per patient was reduced by € 114 in GL XPS versus TURP patients; the cost was higher in the surgical phase with GL XPS (difference: € 1,209; P < .001) but was lower in the post-surgical phase (difference: € –1,351; P < .001).ConclusionsThe GreenLight XPS 180-W laser system is associated with a reduction in costs with respect to transurethral resection of prostate in the surgical treatment of LUTS secondary to PBH. This reduction is due to a shorter inpatient length of stay that offsets the cost of the new technology.     

Day case endourology in surgical outpatient clinic at Ibadan: A 5 year review

ObjectiveTo review our day case endourological practice over a five-year period.Subjects and methodsData was obtained from the endourology day case register and these were analysed using simple statistical methods. Caudal anaesthesia and intravenous sedatives were used for the procedures.ResultsA total of 559 patients underwent endoscopic procedures as day cases. Their ages ranged from 10 to 88 years, with a male to female ratio of 4 to 1. Four hundred and thirty eight (78.4%) were diagnostic and 121 (21.6%) were therapeutic. The main diagnostic procedures were urethrocystoscopy (n = 222), and cystoscopy alone (n = 116), cystoscopy and biopsy (n = 46) while the therapeutic procedures were direct visual internal urethrotomy (n = 86), endoscopic cystolitholapaxy (n = 10), and rigid retrograde endoscopic realignment (n = 7) for posterior urethral injury. The main anaesthesia was caudal block in 472 patients and topical 2% xylocaine jelly with sedation in 86 patients.ConclusionsThere is a steady increase in therapeutic day case endourology. Caudal anaesthesia provides effective pain free procedure to the patient. Surgical trainees can benefit by learning the technique of caudal block anaesthesia.     

Procedimientos quirúrgicos urológicos mayores en el cáncer colorrectal localmente avanzado

ObjectiveTo evaluate the outcomes of major urological procedures performed in patients with locally advanced colorectal cancer.Material and methodsData of 37 patients with locally advanced colorectal cancer who underwent major urological surgical procedures along with simultaneous cancer surgery between the years of 2005 and 2010 were retrospectively evaluated.ResultsThe mean age was 58.3 years. Male/Female ratio was 2.7. 59% of the patients were primary, and 41% were recurrent cases of colorectal cancer. Bladder, ureters, urethra, kidneys and prostate were found as invaded in 19, 9, 5, 2 and 2 cases, respectively. The following single or combined procedures were performed; partial (n = 11) or total (n = 8; 2 combined with urethrocutaneostomy, 6 with ileal-conduit) cystectomy, urethroplasty (n = 5), nephroureterectomy (n = 2), radical nephrectomy (n = 1), partial nephrectomy (n = 1), ureteroneocystostomy (n = 7), Boari's flap (n = 4), transureteroureterostomy (n = 3). Prolonged drainage was the most common surgical complication (27%). Urethrocutaneous fistula and total urinary incontinence were encountered in 1 and 1 patient, respectively. The incidence of hydronephrosis and elevated creatinine were 38% (preoperative 27%; postoperative 11%) and 24% (11% preoperative; 13% postoperative), respectively. Two deaths occurred in the first month of operations. Mean duration of follow up was 18(6-28) months for surviving 13 patients. Overall survival in 24 cases resulting in death was 21(1-42) months.ConclusionsSince the most important eventual effects of locally advanced colorectal cancer are on the kidneys from the urological point of view; the aim of an urologist, as a member of surgical team, should be preserving renal function in addition to helping complete removal of the tumor.     

A comparative study of laparoscopic and robotic assisted radical prostatectomy performed by a single surgeon

ObjectiveTo present the transition from laparoscopic radical prostatectomy (LRP) to robotic-assisted laparoscopic radical prostatectomy (RALP) over 10 years in a medium volume center by a single surgeon.Materials and methodsWe retrospectively reviewed 140 prostate cancer patients who underwent LRP (100 patients) or RALP (40 patients) between May 2005 and May 2015. Preoperative parameters included age, body mass index, and serum prostate specific antigen. Operative course parameters included operative time, estimated blood loss, intraoperative blood transfusion, conversion to open surgery, hospitalization days, duration of Foley catheterization, and complications. Pathological stage, surgical margin status, biochemical recurrence (BCR) rate, and continence rate at 12 months after surgery were reviewed and compared between the LRP and RALP groups.ResultThe operative outcomes revealed significantly less blood loss (143 mL vs. 306 mL, p < 0.001), shorter hospital stay (6.9 days vs. 8.7 days, p = 0.006), and shorter duration of Foley catheterization (9.3 days vs. 11.3 days, p < 0.001) in patients who underwent RALP. Major perioperative complications occurred in four LRP patients (4%), and none were observed in RALP patients. LRP and RALP had similar positive surgical margin rates (p = 0.285) and BCR rates (p = 0.88). RALP resulted in better continence recovery than LRP (55% vs. 82.5%, p = 0.003).ConclusionPatients who underwent RALP had better perioperative and functional outcomes. Oncologic outcomes were similar compared to patients who underwent LRP.     

Multidirectional and simultaneous evaluation of gastroschisis-related intestinal damage in chick embryos

PurposeIn a chick model of gastroschisis, we aimed to investigate the morphological/cellular, molecular, and ultrastructural changes taking place in gastroschisis-related intestinal damage (GRID).Methods13-Day fertilized eggs were divided into two groups. Control group: chorio-amnio-allontoic membranes opened and abdominal wall exposed. Gastroschisis group: an anterior abdominal wall defect created after opening membranes. Embryos from both groups were surgically removed on post-fertilization day 19. Intestinal samples were obtained for histopathology, immunohistochemistry, molecular biology, and electron microscopy.ResultsThe histopathological grade of intestinal damage which primarily involved mucosal structures was significantly higher in the gastroschisis group when compared to the control group (p < 0.001). Immunohistochemically, E-cadherin and synaptophysin immunoreactivity in the gastroschisis group was significantly lower than control group (p < 0.05 and p < 0.01, respectively), whereas there was no significant difference in laminin and type-4 collagen immunoreactivity between the groups (p > 0.05). Molecular analyses indicated a significant decrease in NFκB and IκB expression in the gastroschisis group (p < 0.05 and p = 0.001, respectively). Electron microscopy showed that the gastroschisis group had considerable ultrastructural damage, manifested by apoptosis in all layers.ConclusionsGRID affected all layers but was more prominent in mucosa. The damage may depend on E-cadherin and synaptophysin downregulation. Increased apoptotic activity, associated with decreased NFκB and IκB expression, may be an important component of this multifactorial damaging process.     

Simplified percutaneous large bore suprapubic cystostomy for acute urinary retention—A cost saving procedure

Introduction and objectivesCommercial cystostomy kits/trocars are not always readily available in regions with insufficient funding. Open suprapubic cystostomy procedures are yet prevalent. This paper presents a simplified percutaneous suprapubic cystostomy technique that utilizes specially selected surgical blades in the place of commercial trocars.Subjects and methodsEighty-nine male patients with acute urinary retention underwent puncturing of the visibly and palpably distended bladder with surgical blade size 20 (7 mm diameter), 21 or 22 (9 mm diameter) to allow resistance-free placement of Foley catheter size 18 Fr (maximum diameter of 6 mm) or size 20 (maximum diameter of 6.7 mm) respectively under local anesthesia along the mid abdominal line in a sagittal direction – two finger breadths above the pubic symphysis. The main outcome measures were to determine the success rate and the encountered complications.ResultsSuccessful bladder puncture and insertion of the Foley catheter of choice was possible in all cases. There was no mortality and no adjacent visceral injury. There were two cases of catheter blockage with clots that were easily flushed out.ConclusionsEmergency cystostomy can be safely achieved through direct puncture of the visibly and palpably distended bladder with appropriately selected surgical blades that will subsequently allow resistance-free placement of sizable Foley catheters.     

Postoperative continuous transversus abdominis plane block vs continuous wound infusion of levobupivacaine in females undergoing open gynecologic procedures

IntroductionTransversus abdominis plane (TAP) block is used as a part of multimodal analgesia in decreasing pain of lower abdominal wall incision. Local anesthetic instillation of wounds through subcutaneous or subfascial catheters is used to treat postoperative pain in different types of surgery. The aim of this randomized controlled trial was to study the opioid-sparing effect of these two techniques (if any) compared to placebo in women undergoing gynecologic procedures through transverse lower abdominal incisions.MethodsSeventy-eight ASA I–III patients planned to undergo gynecologic procedures through a transverse lower abdominal incision were randomly divided into three equal groups: Control (C) group (n = 26), Continuous Wound Infusion (CWI) group (n = 26), and continuous transversus abdominis plane block (TAP) group (n = 26). After standardized general anesthetic and before extubation, the patients were given the allocated treatment. A morphine patient-controlled analgesia (PCA) was started postoperatively alongside with the local anesthetic (or placebo) infusion. Cumulative dose of morphine PCA in the first postoperative 48 h was the primary outcome. Secondary outcomes included visual analog pain score (VAS) at rest and on movement and complications of morphine PCA.ResultsThe cumulative dose of morphine PCA in the first postoperative 48 h was higher in control group than in groups CWI and TAP (P < 0.001). However, no significant difference was found between groups CWI and TAP. No significant differences were found among the three groups regarding VAS during rest but TAP group showed less pain scores than groups C and CWI on movement. The three groups were similar regarding morphine side effects.ConclusionContinuous bilateral TAP block and CWI can decrease PCA morphine consumption in the first postoperative 48 h when compared to placebo in women undergoing gynecologic surgery through transverse lower abdominal incision. Continuous TAB block might give better analgesia with movement than CWI.     

Role of Computed tomography in predicting prognosis of Hepatic portal venous gas

BackgroundThe aim of this study was to report through 13 cases the particularities of abdominal computed tomography (CT) aspects of hepatic portal venous gas (HPVG) and its correlation with patient prognosis.MethodsWe analyzed abundance of HPVG and its association with pneumatosis intestinalis (PI) in correlation with fatal outcome using chi-square tests.ResultsEtiologies were mesenteric infarction (n = 5), sigmoid diverticulitis (n =  1), septic shock (n = 1), postoperative peritonitis (n = 1), acute pancreatitis (n = 1), iatrogenic cause (n = 3) and idiopathic after a laparotomy (n = 1). The outcome was fatal in for 6 patients. Abundance of HPV was expressed in total number of hepatic segments involved. The involvement of 3 or more segments was a sensitive sign for lethal outcome with high sensitivity (100%) but it was not specific (50%). Negative predictive value of this sign was 100% (p ≤ 0.005). Positive predictive value of PI for death was 100% (p ≤ 0.001).DiscussionAbundance of HPVG is correlated with prognosis. The presence of PI announces poor outcome Negative predictive value of presence of HPVG in 3 or more segments is interesting. Predicting prognosis with CT can help surgeons to assess the most adequate treatment. Iatrogenic causes are increasingly described after interventional radiology procedures with favorable course.ConclusionThe first etiology radiologists should look for in front of HPVG involving more than 3 hepatic segments and associated with PI is intestinal necrosis which announces a poor prognosis. This study shows that outside of shock situations, HPVG involving 2 or less hepatic segments without PI predicts a good outcome.