Efficacy and Safety of Seprafilm for Preventing Postoperative Abdominal Adhesion: Systematic Review and Meta-analysis

Background There is no clear consensus on the efficacy and safety of hyaluronate-carboxymethylcellulose membrane (Seprafilm) for preventing postoperative abdominal adhesion. This study is a meta-analysis of the available evidence. Methods A search of the MEDLINE, EMBASE, and the Cochrane Library identified eight studies that met the inclusion criteria for data extraction. Estimates of effectiveness were performed using fixed- and random-effects models. The effect was calculated as an odds ratio (OR) with 95% confidence intervals (CI) using the statistical software Review Manager Version 4.2. Level of significance was set at p < 0.05. Results Outcomes of 4203 patients were studied. The incidence of grade 0 adhesions among Seprafilm-treated patients was statistically significantly more than that observed among control group patients (OR 95%CI, 3.74–20.34; p < 0.01). There was no significant difference in the incidence of grade 1 adhesions between Seprafilm and control groups (OR 95%CI, 0.58–2.71; p = 0.56). The severity of grade 2 and grade 3 adhesions among Seprafilm-treated patients was significantly less than that observed among control group patients (OR 95%CI, 0.22–0.93; p = 0.03; OR 95%CI, 0.09–0.63; p < 0.01, respectively). The incidence of intestinal obstruction after abdominal surgery was not different between Seprafilm and control groups (OR 95%CI, 0.78–1.23; p = 0.84). Using Seprafilm significantly increased the incidence of abdominal abscesses (OR 95%CI, 1.06–2.54; p = 0.03) and anastomotic leaks (OR 95%CI, 1.18–3.50; p = 0.01). Conclusions Our systematic review and meta-analysis showed that Seprafilm could decrease abdominal adhesions after general surgery, which may benefit patients, but could not reduce postoperative intestinal obstruction. At the same time, Seprafilm did increase abdominal abscesses and anastomotic leaks.     

Laparoscopic fundoplication: A 10-year learning curve

Background Laparoscopic Nissen fundoplication (LNF) has become the most common surgical treatment for gastroesophageal reflux disease (GERD). Controversies still exist regarding the operative technique and the durability of the procedure. Methods A retrospective study of 808 patients undergoing 838 LNF for GERD at a tertiary referral center was undertaken. Demographic, perioperative, and follow-up data had been entered onto the unit database. Results During a median follow-up period of 60 months (range, 2–120 months), heartburn decreased to 3% of the patients (19/645) and regurgitation to 2% (11/582) (p < 0.01). Respiratory symptoms improved in 69 (85%) of 81 patients (p < 0.01). The incidence of postoperative dysphagia was unaffected by the use of an intraesophageal bougie (odds ratio [OR], 1.16; 95% confidence interval [CI], 0.82–1.64; p = 0.41) or division of the short gastric vessels (OR, 0.84; 95% CI, 0.42–1.07; p = 0.72). In the immediate postoperative period, the incidence of abdominal symptoms increased by 10% (p < 0.01) and dysphagia by 16% (p < 0.01). After 10 postoperative years, only 3% (30/484) were found to have abdominal symptoms, whereas the incidence of dysphagia declined to zero. Conclusion The findings show that LNF is a safe and effective procedure with long-term durability. Abdominal symptoms and dysphagia are the principal postoperative complaints, which improve with time. Personal preference should dictate the use of a bougie, division of the short gastric vessels, or both.     

Impact of Mild Acute Kidney Injury (AKI) on Outcome after Open Repair of Aortic Aneurysms

Recently, mild AKI has been considered as a risk factor for mortality in different scenarios. We conducted a retrospective analysis of the risk factors for two distinct definitions of AKI after elective repair of aortic aneurysms. Logistic regression was carried out to identify independent risk factors for AKI (defined as $25% or $50% increase in baseline SCr within 48 h after surgery, AKI 25% and AKI 50%, respectively) and for mortality. Of 77 patients studied (mean age 68 ± 10, 83% male), 57% developed AKI 25% and 33.7% AKI 50%. There were no differences between AKI and control groups regarding comorbidities and diameter of aneurysms. However, AKI patients needed a supra-renal aortic cross-clamping more frequently and were more severely ill. Overall in-hospital mortality was 27.3%, which was markedly higher in those requiring a supra-renal aortic cross-clamping. The risk factors for AKI 25% were supra-renal aortic cross-clamping (odds ratio 5.51, 95% CI 1.05–36.12, p?=?0.04) and duration of operation for AKI 25% (OR 6.67, 95% CI 2.23–19.9, p < 0.001). For AKI 50%, in addition to those factors, post-operative use of vasoactive drugs remained as an independent factor (OR 6.13, 95% CI 1.64–22.8, p?=?0.005). The risk factors associated with mortality were need of supra-renal aortic cross-clamping (OR 9.6, 95% CI 1.37–67.88, p?=?0.02), development of AKI 50% (OR 8.84, 95% CI 1.31–59.39, p?=?0.02), baseline GFR lower than 49 mL/min (OR 17.07, 95% CI 2.00–145.23, p?=?0.009), and serum glucose > 118 mg/dL in the post-operative period (OR 19.99, 95% CI 2.32–172.28, p?=?0.006). An increase of at least 50% in baseline SCr is a common event after surgical repair of aortic aneurysms, particularly when a supra-renal aortic cross-clamping is needed. Along with baseline moderate chronic renal failure, AKI is an independent factor contributing to the high mortality found in this scenario.     

The association between personal habits and bladder cancer in Turkey

Aims  In this study, we analyzed the effect of Turkish coffee and black tea consumption, alcohol intake and smoking on bladder cancer. Methods  A total of 164 patients with bladder tumors and 324 individuals without primary tumors were included in the study. The habits of coffee and tea consumption, alcohol intake and smoking were queried. Results  No association was found between bladder cancer and drinking coffee (p = 0.89) and tea (p = 0.37), but alcohol intake was found to be associated, with an odds ratio (OR) of 1.85 (95% CI 1.15–2.96; p = 0.009). While there was a relationship between bladder cancer and smoking and quitting smoking (OR: 4.84 [95% CI 2.93–8.00; p < 0.001] and OR: 4.10 [95% CI 2.41–6.97; p < 0.001] respectively), the associations between bladder cancer and smoking and quitting smoking were similar (OR: 1.18, 95% CI 0.74–1.86; p = 0.477). Smoking <10 cigarettes a day created an OR of 2.14 (95% CI 1.11–4.12; p < 0.001); 10–20 cigarettes an OR of 4.50 (95% CI 2.74–7.37; p < 0.001); >20 cigarettes an OR of 14.85 (95% CI 6.83–32.27; p < 0.001); smoking by inhaling the smoke an OR of 4.72 (95% CI 2.94–7.59; p < 0.001), and smoking by not inhaling the smoke an OR of 3.34 (95% CI 1.75–6.38; p < 0.001). The associations between bladder cancer and inhaling smoke and not inhaling smoke were similar (OR: 1.41, 95% CI 0.85–2.48; p = 0.228). Conclusion  We found that smoking and alcohol consumption are closely connected with bladder cancer. Our data showed that not inhaling the smoke was as much associated with bladder cancer as inhaling the smoke. The association between smoking and bladder cancer lasts after quitting smoking.     

Comparative clinical outcomes between pediatric and young adult dialysis patients

Published data on the comparative achievement of The Kidney Disease Dialysis Outcome Quality Initative (KDOQI) recommended clinical performance targets between children and young adults on dialysis are scarce. To characterize the achievement of KDOQI targets among children (<18 years) and young adults (18–24 years) with prevalent end stage renal disease (ESRD), we performed a cross-sectional analysis of data collected by the Mid-Atlantic Renal Coalition, in conjunction with the 2007 and 2008 ESRD Clinical Performance Measures Projects. Data on all enrolled pediatric dialysis patients, categorized into three age groups (0–8, 9–12, 13–17 years), and on a random sample of 5% of patients ≥18 years in ESRD Network 5 were examined for two study periods: hemodialysis (HD) data were collected from October to December 2006 and from October to December 2007 and peritoneal dialysis (PD) data were collected from October 2006 to March 2007 and from October 2007 to March 2008. In total, 114 unique patients were enrolled the study, of whom 41.2% (47/114) were on HD and 58.8% (67/114) on PD. Compared to the pediatric patients, young adults were less likely to achieve the KDOQI recommended serum phosphorus levels and serum calcium × phosphorus product values, with less than one-quarter demonstrating values at or below each goal. Multivariate analysis revealed that both young adults and 13- to 17-year-olds were less likely to achieve target values for phosphorus [young adults: odds ratio (OR) 0.04, 95% confidence interval (95% CI) 0.01–0.19, p < 0.001; 13- to 17-year-olds: OR 0.17, 95% CI 0.04–0.77, p = 0.02] and calcium × phosphorus product (young adults: OR 0.01, 95% CI 0.002–0.09, p <  0.001; 13- to 17-year-olds: OR 0.09, 95% CI 0.02–0.56, p = 0.01) than younger children. In summary, there are significant differences in clinical indices between pediatric and young adult ESRD patients.     

Umbilical Herniorrhapy in Cirrhosis: Improved Outcomes with Elective Repair

Objective This study was undertaken to examine the effect of cirrhosis on elective and emergent umbilical herniorrhapy outcomes. Methods Procedures were identified from the Veterans’ Affairs National Surgical Quality Improvement Program at 16 hospitals. Medical records and operative reports were physician abstracted to obtain preoperative and intraoperative variables. Results Of the 1,421 cases reviewed, 127 (8.9%) had cirrhosis. Cirrhotics were more likely to undergo emergent repair (26.0% vs. 4.8%, p < 0.0001), concomitant bowel resection (8.7% vs. 0.8%, p < 0.0001), return to operating room (7.9% vs. 2.5%, p = 0.0006), and increased postoperative length of stay (4.0 vs. 2.0 days, p = 0.01). Best-fit regression models found cirrhosis was not a significant predictor of postoperative complications. Significant predictors of complications were emergent case (OR 5.4; 95% CI 3.1–9.4), diabetes (OR 2.1; 95% CI 1.2–3.8), congestive heart failure (OR 4.0; 95% CI 1.4–11.4), and chronic obstructive pulmonary disease (OR 2.0; 95% CI 1.1–3.6). Among emergent repairs, cirrhosis (OR 4.4; 95% CI 1.3–14.3) was strongly associated with postoperative complications. Conclusion Elective repair in cirrhotics is associated with similar outcomes as in patients without cirrhosis. Emergent repair in cirrhotics is associated with worse outcomes. Early elective repair may improve the overall outcomes for patients with cirrhosis.     

Pregnancy Following Gastric Bypass Surgery for Morbid Obesity: Maternal and Neonatal Outcomes

Background The purpose of this study was to compare obstetric and neonatal outcomes after Roux-en-Y gastric bypass (RYGB) to those in women without such surgery. Methods Women with RYGB (cases) were matched for maternal age and prior cesarean to the next two consecutive women delivering without prior bariatric surgery (controls). Pregnancy and newborn outcomes were compared by univariate analysis. Outcomes approaching or reaching statistical significance were evaluated by conditional logistic regression controlling for maternal body mass index (BMI). Results Despite gastric bypass, the 38 cases were heavier (BMI 33.4 ± 7.3 vs. 28.1 ± 6.7 kg/m², p < 0.001) and more often obese (BMI ≥ 30 kg/m², 26/38 (68.4%) vs. 20/76 (26.3%), p < 0.001) than controls. Variables evaluated by logistic regression adjusted for BMI did not differ in cases versus controls, including hypertension (odds ratio [OR] 2.62, 95% confidence interval [CI] 0.66–10.50), preterm premature rupture of membranes (OR 0.24, 95% CI 0.02–3.38), oligohydramnios (OR 2.39, 95% CI 0.66–8.61), and delivery ≥41 weeks (OR 0.57, 95% CI 0.11–2.97). Discussion Obstetric and neonatal outcomes after RYGB are similar to those of our general obstetric population. Reprints unavailable.     

Risk Factors for Hypoxemia After Surgery for Acute Type A Aortic Dissection

Purpose Postoperative hypoxemia is a frequent complication of surgery for acute type A aortic dissection. We tried to determine the factors associated with postoperative hypoxemia. Methods Between 1997 and 2003, 114 patients underwent surgery for acute type A aortic dissection. Multivariate logistic regression analysis was done to identify the independent predictors of postoperative hypoxemia, defined by an arterial partial oxygen/inspired oxygen fraction (PaO₂/FiO₂) ratio of 200 or lower. Results The overall in-hospital mortality was 6.1% (7 of 114 patients), being 5.2% in the hypoxemia group and 6.9% in the non-hypoxemia group. The ventilation time and intensive care unit stay were significantly longer in the hypoxemia group than in the non-hypoxemia group (P = 0.0044, P = 0.038, respectively). Logistic regression identified the following variables as predictors for postoperative hypoxemia: body mass index ≥25 (odds ratio [OR], 5.6; 95% confidence interval [CI], 2.1–15.01; P < 0.001), preoperative PaO₂/FiO₂ ratio ≤300 (OR, 2.6; 95% CI, 1.09–6.13; P = 0.031), and the volume of transfused blood (OR, 1.08; 95% CI, 1.01–1.18; P = 0.037). Conclusions Initiating early treatment for hypoxemia and reducing the volume of blood transfused intraoperatively may improve the postoperative clinical course of obese patients with preoperative hypoxemia.     

Comparative early and midterm results of open juxtarenal and infrarenal aneurysm repair

Background and aims Since the introduction of endovascular aortic aneurysm repair (EVAR) for aortic aneurysms, the number of juxtarenal aortic aneurysms (JRA) has been growing steadily due to selection bias (neck morphology for EVAR). This case-match study compares the perioperative outcome and midterm results of suprarenally clamped JRA with infrarenal aortic aneurysms (AAA). Methods From 1997 to 2004, patients who received open surgery with suprarenal clamping for JRA were included in the study and compared to matched patients with infrarenal clamping (AAA). Measurements analyzed were the in-hospital mortality and morbidity. Midterm results were obtained through clinical investigation and magnetic resonance angiography imaging. Results Thirty-five patients (mean age, 68.4 years; 30 male and 5 female) received suprarenal cross-clamping for JRA. The overall in-hospital mortality for JRA and for the controls (AAA) with elective aortic repair was 4.5% (6.1% JRA; 3% AAA, p = 0.058). The morbidity of JRA was elevated according to the rate of pulmonary complications (p = 0.021) and the need for re-operation (p = 0.019). The mean follow-up time was 2.3 years (range, 8–96 months). At follow-up, 28 patients (80%) from the JRA group and 29 patients from the AAA group (82.9%) were alive. Conclusion Open aortic surgery for JRA with the need for suprarenal cross-clamping shows a slightly elevated in-hospital mortality rate without statistical significance and equal midterm mortality results in comparison with infrarenally clamped aortic aneurysms.     

Cohort Study of Fever and Leukocytosis as Diagnostic and Prognostic Indicators in Infected Surgical Patients

The presence of fever and leukocytosis have traditionally been utilized as important diagnostic markers of infection despite some who question their reliability. To examine this point, the role of fever and leukocytosis as diagnostic and prognostic indicators for surgical infections was evaluated. A prospective observational study was performed on all patients with suspected infection in 1997 on the general surgical services at a university hospital. Fever was defined as maximum temperature (Tmax) ≥ 38.5°C, and leukocytosis was defined as a white blood cell (WBC) count ≥ 11,000/μl. Among all infections, patients presenting with a Tmax ≥ 38.5°C were younger (51.3 ± 1.1 vs. 53.8 ± 0.9 years, p= 0.005) and had a higher APACHE II score (15.1 ± 0.5 vs. 11.4 ± 0.4; p < 0.001). By logistic regression analysis chronic renal insufficiency was associated with a Tmax < 38.5°C [odds ratio (OR) 0.371, 95% confidence interval (CI) 0.195–0.704], and chronic steroid therapy was associated with a WBC count < 11,000/μl (OR 0.556, 95% CI 0.335–0.921). In addition, infected transplant patients were more likely to present with a Tmax < 38.5°C and a WBC count < 11,000/μl (OR 0.195, 95% CI 0.075–0.502). Mortality rates for infected patients with a Tmax < 38.5°C or > 38.5°C were 11.6% and 12.9%, respectively (p < 0.7), and the lengths of stay were 14 ± 1 and 18 ± 1 days, respectively (p < 0.03). Mortality rates for patients with a WBC count < 11,000/μl or > 11,000/μl were 4.7% and 18.6%, respectively (p < 0.001), and the lengths of stay were 14 ± 1 and 19 ± 1 days, respectively (p < 0.001). In the setting of infection, chronic renal insufficiency and chronic steroid therapy are associated with suppression of fever and leukocytosis, respectively. Transplantation is an independent predictor of infection in patients presenting without fever or leukocytosis. Leukocytosis, but not fever, may be predictive of hospital mortality in infected surgical patients.     

Ruptured de novo intracranial aneurysms

Summary Objective. We describe the actual state of ruptured de novo intracranial aneurysms to contribute to a guideline of follow-up for the patients with treated intracranial aneurysm.Methods. The authors retrospectively investigated 12 cases drawn from 483 consecutive cases of aneurysmal subarachnoid hemorrhage at our institute over a period of 22 years, in which a previously undemonstrated (hence de novo) intracranial saccular aneurysm formed and ruptured after successful treatment of a prior aneurysm.Findings. The 12 cases constitute 2.5% of the 483 patients who left our hospital alive. Eleven cases were females and one was a male with a mean age of 55.7 years (range 29–75) at the first subarachnoid haemorrhage (SAH) and an interval between the first and the second rupture of 10.7 years (range: 2.6–23.8, standard deviation: 6.86, 95% confidence interval: 6.39–15.1). Four cases did not have risk factors such as hypertension, family history, smoking, multiple aneurysms, and moyamoya disease. None of these ruptured de novo aneurysms was at the same location as the original lesion. One-third (4 cases) of the de novo lesions in our series were found on the opposite side to each prior lesion.Interpretation. For not only young but also elder patients with a treated aneurysm (from the fifth decade to the sixth), especially for women, late angiography or alternative modalities of less-invasive examination should be considered. To detect de novo intracranial aneurysms before rupture, the search for a de novo aneurysm should be performed within 6.39 years after a previous examination that shows an aneurysm to be nonexistent, in view of the 95% confidence interval of the mean time to de novo aneurysmal rupture (6.39–15.1 years). If applied this survey, 75% (8 cases of 12 cases) of our de novo aneurysms would be detected before rupture.     

Laparoscopic versus open approach for implantation of the peritoneal catheter during ventriculoperitoneal shunt placement

Background  Ventriculoperitoneal shunt (VPS) is the mainstay of therapy for hydrocephalus. The aim of this study is to compare outcomes of laparoscopic (LVPS) versus open (OVPS) techniques for placement of distal VPS catheters. Methods  All patients undergoing new VPS placement at a tertiary care center between January 2004 and August 2007 were included. Univariate analysis was performed. Wilcoxon rank-sum, chi-square, and Fisher’s exact tests were used to make comparisons between LVPS and OVPS groups. Stepwise backward logistic regression was performed to predict complications requiring operative intervention. A Kaplan–Meier estimate of the survival function was calculated for shunt survival. All data is presented as median and range unless otherwise specified. Results  Five hundred thirty-five consecutive patients underwent 579 VPS (258 LVPS, 321 OVPS). Median age (52.0 years) and American Society of Anesthesiologists (ASA) score (3) were similar in LVPS and OVPS groups. Body mass index (BMI) [27.8 (17.0–64.9) kg/m² versus 25.9 (12.3–44.4) kg/m², p = 0.007], previous operations [0.8 ± 0.9 versus 0.6 ± 0.7, p = 0.004 (mean ± standard deviation)], estimated blood loss (EBL) [20 (0–175) ml versus 25 (0–500) ml, p < 0.001], operating room (OR) time [37.5 (17.0–152.0) min versus 52.0 (20.0–197.0) min, p < 0.001], and length of stay (LOS) [11 (1–77) days versus 14 (1–225) days, p = 0.016] were statistically different between the LVPS and OVPS groups, respectively. LVPS abdominal complication rate of 5.8% and OVPS rate of 6.9% were similar (p = 0.611). Previous abdominal operation [odds ratio (OR) 1.673, 95% confidence interval (CI) 1.100–2.543, p = 0.016] and previous VPS (OR 1.929, 95% CI 1.147–3.243, p = 0.016) were significant predictors of complications requiring operative intervention. Kaplan–Meier analysis demonstrated no difference in survival between LVPS and OVPS groups (p = 0.538), with overall shunt survival of 86.4% at 6 months and 83.0% at 1 year. Conclusions  LVPS is associated with decreased OR time, less blood loss, and shorter LOS with no difference in complication rate when compared OVPS. The laparoscopic approach for VPS is a safe, effective, and readily reproducible alternative to the traditional open approach.     

Fracture Risk Associated with Use of Nonsteroidal Anti-Inflammatory Drugs, Acetylsalicylic Acid, and Acetaminophen and the Effects of Rheumatoid Arthritis and Osteoarthritis

We studied the effects of various nonmorphine pain medications as well as rheumatoid arthritis and osteoarthritis on fracture risk in a nationwide case-control study. Cases were all subjects with any fracture sustained during the year 2000 (n = 124,655) in Denmark. For each case, three controls (n = 373,962) matched on age and gender were randomly drawn from the background population. The primary exposure variables were use of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), or acetylsalicylic acid (ASA). Adjustments were made for several confounders. The effect of dose was examined by stratifying for cumulated dose (defined daily dose, DDD). For acetaminophen, a small increase in overall fracture risk was observed with use within the last year (odds ratio [OR] = 1.45, 95% confidence interval [CI] 1.41–1.49). For ASA, no increase in overall fracture risk was present with recent use. Significant heterogeneity was present for the NSAIDs; e.g., ibuprofen was associated with an increased overall fracture risk (OR = 2.09, 95% CI 2.00–2.18 for <20 DDD), while celecoxib was not (OR = 0.76, 95% CI 0.51–1.13 for <20 DDD, 2P < 0.01 for comparison). Osteoarthritis was associated with a decreased risk of any fracture if the diagnosis had been made more than 1 year ago (OR = 0.70, 95% CI 0.67–0.72). Rheumatoid arthritis was associated with an increase in overall fracture risk if the diagnosis had been made within the last year (OR = 1.86, 95% CI 1.68–2.07). Weak analgesics may be associated with fracture risk in a varying way. The effects in most cases were small. Falls may be one reason for the increase in fracture risk with some NSAIDs.     

Gender and vesico-ureteral reflux: a multivariate analysis

The aim of this retrospective cohort study was to describe the characteristics of patients with primary vesico-ureteral reflux (VUR) with special attention to gender-specific differences. Between 1970 and 2004, 735 patients were diagnosed with VUR and were systematically followed in a single tertiary renal unit. The following variables were analyzed: race, age at diagnosis, clinical presentation, weight and height Z-score, unilateral/bilateral reflux, VUR grade, renal damage, severity of renal damage, constipation, and dysfunctional voiding. Comparison of proportion between genders was assessed by the chi-square test with Yates’ correction. The logistic regression model was applied to identify independent variables associated with gender. A survival analysis was performed to evaluate VUR resolution. After adjustment, five variables remained independently associated with male gender at baseline: non-white race [Odds ratio (OR) = 1.98, 95% confidence interval (95% CI) 1.33–2.95, P=0.001], moderate/severe grade of reflux (OR=2.16, 95% CI 1.45–3.22, P<0.001), severe renal damage (OR=1.60, 95% CI 1.04–2.52, P=0.04), age at diagnosis <24 months (OR=1.79, 95% CI 1.23–2.60, P=0.002), and antenatal clinical presentation (OR=3.56, 95% CI 1.91–6.63, P<0.001). Follow-up data were available for 684 patients (93%). Median follow-up time was 69 months (range 6 months to 411 months). Girls had a greater risk of urinary tract infection (UTI) during follow-up than boys (OR=1.68, 95% CI 1.18–2.38, P=0.003). There was no difference in progression to chronic renal insufficiency (CRI) between boys (3.8%) and girls (2.4%) during this period of follow-up (OR=1.58, 95% CI 0.59–4.15, P=0.44). Gender as an isolated variable is a poor predictor of clinical outcome in an unselected series of primary reflux. Although boys had a more severe pattern at baseline, girls had a greater risk of dysfunctional voiding and recurrent UTI during follow-up.     

Factors Associated with Postoperative Cognitive Dysfunction in Patients Undergoing Cardiac Surgery

Purpose Central nervous system complications continue to be major causes of morbidity and mortality after cardiac surgery. The purpose of this study was to identify the risk factors for postoperative cognitive dysfunction after coronary artery bypass graft (CABG) surgery. Methods Eighty-eight patients scheduled for elective CABG were studied. After the induction of anesthesia, a fiberoptic oximetry oxygen saturation catheter was inserted into the right jugular bulb for the continuous monitoring of jugular venous oxygen hemoglobin saturation (SjvO₂). The hemodynamic parameters and arterial and jugular venous blood gases were measured during cardiopulmonary bypass (CPB). All patients underwent a battery of neurological and neuropsychological tests one day before the operation and at 6 months after the operation. Results The incidence of a cognitive decline at 6 months was 24/88 (27.3%). Greater age (P = 0.04), the presence of renal failure (P < 0.001), and diabetes mellitus (P < 0.001) were more frequent in the patients with postoperative cognitive dysfunction at 6 months after the operation than in patients without cognitive dysfunction. Age (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.0–1.7; P = 0.04), diabetes mellitus (OR, 1.8; 95% CI, 1.2–2.4; P < 0.01), and presence of renal failure (OR, 2.8; 95% CI, 2.4–4.3; P < 0.01) were associated with cognitive impairment at 6 months postoperatively. However, there was no relationship between the presence of atherosclerosis in the ascending aorta and postoperative cognitive dysfunction after CABG surgery. Conclusions A greater age, diabetes mellitus, and renal failure were found to be risk factors for development of cognitive impairment at 6 months after CABG with CPB.     

Pain intensity and severe pain in young immigrant patients with long-standing back pain

The aim of this study was to explore if self-rated pain intensity and severe pain differed significantly between immigrants from different regions, and if other socio-economic, or clinical, characteristics could predict severe pain. A total of 129 men and 217 women at a primary health centre in Stockholm, Sweden, 27–45 years, on long-term sick leave, were recruited in consecutive order and grouped into a Turkish (n = 122), Southern European (n = 52), Middle East (n = 69) and one Mixed (n = 173) group of immigrants. All were employed in service jobs. Somatic status, depression and level of psychosocial stressors, including pain anxiety, were established by standardized procedures. All reported long-standing disabling back pain. Patients rated intensity of pain “right now” on a 0–100 mm visual analogue scale (VAS) as a last part of the consultation with two doctors. Severe pain was defined as VAS 75–100. Median values (md) with inter-quartile ranges (IQR) were calculated for interval and ordinal data. Non-parametric statistics were used to calculate significant differences between groups. Crude and age-standardized odds ratios (OR) with 95% confidence intervals (95% CI) as rating severe pain were calculated by binary and forward conditional logistic regression. Men and women were analyzed separately. Women had more tender points, (P < 0.001), and reported pain anxiety more often (P < 0.01). Frequency of depression did not differ between the immigrant groups. The VAS-values varied, but not significantly, between the immigrant groups of men and women. Men had lower VAS values than women (md 50, IQR 36–69 vs. md 72, IQR 51–85), (P < 0.001). Women had a three-fold risk to rate severe pain (OR 2.9, 95% CI 1.8–4.7). By sex, no immigrant group had significantly elevated OR to rate severe pain. Being 40–45 year old doubled the OR as rating severe pain. Men with depression, or little education, had high risks as rating severe pain (age-standardized ORs 4.1; 95% CI 1.7–10.0 and 2.7; 95% CI 1.1–6.8, respectively), and so had depressed women (age-standardized OR 1.9; 95% CI 1.1–3.4). Women with pain anxiety had a doubled, not statistically significant, elevated risk (age-standardized OR 2.0, 95% CI 0.95–4.3). The groups did not differ significantly in pain intensity or severe pain. Severe pain was predicted by depressed mood and probably linked to gender, age and sick roles.     

Securing the appendiceal stump in laparoscopic appendectomy: evidence for routine stapling?

Background This metaanalysis aimed to compare endoscopic linear stapling and loop ligatures used to secure the base of the appendix. Methods Randomized controlled trials on appendix stump closure during laparoscopic appendectomy were systematically searched and critically appraised. The results in terms of complication rates, operating time, and hospital stay were pooled by standard metaanalytic techniques. Results Data on 427 patients from four studies were included. The operative time was 9 min longer when loops were used (p = 0.04). Superficial wound infections (odds ratio [OR], 0.21; 95% confidence interval (CI), 0.06–0.71; p = 0.01) and postoperative ileus (OR, 0.36; 95% CI, 0.14–0.89; p = 0.03) were significantly less frequent when the appendix stump was secured with staples instead of loops. Of 10 intraoperative ruptures of the appendix, 7 occurred in loop-treated patients (p = 0.46). Hospital stay and frequency of postoperative intraabdominal abscess also were comparable in loop-treated and staple-treated patients. Conclusions The clinical evidence on stump closure methods in laparoscopic appendectomy favors the routine use of endoscopic staplers.     

Publication bias in neurosurgery: lessons from series of unruptured aneurysms

Summary.  Background: Bias favouring publication of research with “positive” results over studies with “negative” results is widely suspected. The present investigation addressed this problem in the field of neurosurgery through a review of recent literature concerning outcome of surgery for unruptured intracranial aneurysms.  Methods and findings: A Medline search was performed seeking case series of surgical treatment for unruptured intracranial aneurysms that analyzed 50 or more patients. Ten type I studies (retrospective studies from a single institution; 1457 patients) met these entry criteria. In general, type I studies reported excellent surgical outcome, with mean combined mortality and morbidity of 7.8% (95% confidence interval (CI), 6.4% to 9.2%). We found 4 multicenter or community-based studies (type II studies; 5401 patients). Mean combined mortality and morbidity in the type II studies was 20.3% (95% CI, 19.2% to 21.4%), much higher than in type I studies. Relative risk was 2.6 (95% CI, 2.2 to 3.1) for patients in type II studies compared with those in type I studies. Two meta-analyses (type III studies) described combined mortality and morbidity of 5.0% and 12.7%, essentially corresponding to results of type I studies.  Interpretation: Publication bias is present in the neurosurgical literature. Studies with an excellent surgical outcome are more likely to be published than those with an average outcome. Conclusions of literature reviews or meta-analyses based on published work therefore may be misleading. The solution to the problem would be community-based prospective registration of all patients who underwent surgery, providing a sampling frame free from publication bias. Published online January 14, 2003  Correspondence: Yuhei Yoshimoto, M.D., Department of Neurosurgery, Koshigaya Hospital, Dokkyo University School of Medicine, 2-1-50 Minami-Koshigaya, Koshigaya, Saitama 343-8555, Japan.     

Risk of spinal cord ischemia after fenestrated or branched endovascular repair of complex aortic aneurysms

Objective

The aim of our study was to analyze the incidence of spinal cord ischemia (SCI) in patients presenting with complex aortic aneurysms treated with endovascular aneurysm repair (EVAR) and to identify risk factors associated with this complication.