Can a pressure-limited vesico-amniotic shunt tube preserve normal bladder function?

Introduction

We have previously shown that a vesico-amniotic shunt (V-A shunt) produces fibrotic bladders with poor compliance in normal fetal lambs. We hypothesized that using a ventriculo-peritoneal shunt (V-P shunt) as a V-A shunt in normal bladders may preserve the filling/emptying cycle and normal bladder development.

Materials and methods

The V-A shunting in normal fetal lambs was performed at 74 days of gestation using a V-P shunt (group A) and a free-draining shunt tube (group B). Sham-operated lambs were used as controls (group C). They were all delivered at term (145 days), and the pressure-volume curve, bladder volume, and histologic features of the bladder wall were compared.

Result

The mean bladder volume in group B (n = 5), 5 ± 2.4 mL, was significantly smaller (P < .01) than that in group A (n = 6), 53 ± 14 mL, and group C (n = 10), 57.3 ± 12 mL. The bladder wall thickness in group A was 338 + 94.2 μm; group B, 741 ± 128 μm; and group C, 374 ± 120 μm. Group B bladders had very poor compliance with thick bladder wall (P < .01). Histologically, group B bladders showed prominent submucosal fibrotic change, but group A bladders were similar to controls.

Conclusion

This study shows that a pressure-limited shunt tube for V-A shunting preserves the normal fetal bladder development.     

Can insertion length for a double-lumen endobronchial tube be predicted?

It has been suggested that the appropriate length of insertion for double-lumen tubes can be estimated by external measurement. This study examined the accuracy of external measurement in estimating the actual length of insertion required in 130 patients. It also examined the relationship between the length inserted and the patient's height in 126 patients and their weight in 125 patients. Although there was a fair correlation between the measured external length and the final inserted length (r = 0.61), the 95% confidence intervals of slope and intercept allowed a large variation and the prediction was too wide to be clinically useful. Height was reasonably well correlated with the final length (r = 0.51) but an equally wide 95% confidence interval rendered it of little clinical value. There was no correlation between weight and final tube length. It is concluded that external measurement alone is not adequate to predict a clinically acceptable position of the double-lumen tube.     

Thoracoabdominal radical nephrectomy: is a postoperative thoracostomy tube necessary?

OBJECTIVES: To report our results of patients undergoing thoracoabdominal radical nephrectomy without intraoperative placement of a thoracostomy tube. It has been routine in our hospital to not place a thoracostomy tube in patients undergoing thoracoabdominal radical nephrectomy since 1988. METHODS: We conducted a retrospective review of 47 thoracoabdominal radical nephrectomies performed from January 1988 through November 1998 at our institution. Of the 47 patients, 39 did not have a thoracostomy tube placed intraoperatively; the other 8 patients did. The development of all postoperative complications, length of hospital stay, and hospital charges were noted. RESULTS: No postoperative mortality was noted in our study. Of the 47 patients in the study, 20 patients had a total of 29 complications. The overall number of complications was not increased in the group without a thoracostomy tube compared with the group with a thoracostomy tube (P = 0.104). No patient treated without a thoracostomy tube required subsequent placement of a tube for persistent pneumothorax. The mean length of hospital stay in patients with a thoracostomy tube after radical nephrectomy was 9.14 +/- 2.65 days; in patients without a thoracostomy tube, the mean length of stay was 7.07 +/- 3.97 days (P = 0.071). CONCLUSIONS: In patients without parietal pleural injury, thoracoabdominal radical nephrectomy without the placement of a thoracostomy tube can be performed safely and effectively, with a low risk of postoperative complications and a decrease in the overall hospital stay and hospital charges.     

Does an antibiotic nail made in a lubricated tube release antibiotic?

Introduction

The treatment of long-bone osteomyelitis has long been a difficult problem. Recently, antibiotic-impregnated intramedullary rods for the treatment of infected long-bone fractures have been gaining popularity but they are quite difficult to fabricate. Recently, a new technique that utilizes mineral oil to coat the inside of a chest tube mold prior to introduction of cement has been proven to ease fabrication. We hypothesized that the use of mineral oil would alter the elution characteristics of tobramycin from the intramedullary device.

Methods

Two groups of antibiotic nails were fabricated under sterile conditions. The control group utilized a chest tube mold. The study group utilized a chest tube that was coated with mineral oil prior to cement injection. Each intramedullary nail was placed in pooled human serum and incubated under physiologic conditions. The level of tobramycin in each sample was measured at timepoints 0, 1, 6, and 24 h.

Results

There was no significant difference when comparing control with the experimental group at any timepoint. Antibiotic nails eluted tobramycin at a rapid rate in the first 6 h of exposure to serum, regardless of their preparation with oil or without oil. The rate of elution fell precipitously between 6 and 24 h.

Conclusion

We believe that although this study, as with any study, cannot perfectly recreate in vivo conditions, we have clearly shown that mineral oil has no significant effect on elution of tobramycin from antibiotic nails.

     

Case report of ovary and fallopian tube as content of a Spigelian hernia – a rare entity

IntroductionSpigelian hernia is a rare entity, comprising 1–2% of all hernias. Various abdominopelvic viscera herniate through the defect in the Spigelian fascia and become incarcerated. Specifically in females, the ovary and/or the fallopian tube can herniate through this defect. This is the third reported case of such a hernia.Presentation of caseWe report here a young lady aged 30 years with right-sided ovarian Spigelian hernia. She presented with a painful lump in the right lower quadrant of abdomen for 2 weeks. On examination, she had a tender irreducible lump below and to the right lateral to the umblilicus. CECT revealed a right-sided ovarian Spigelian hernia. The finding was confirmed at exploration and herniorrhaphy performed. She was discharged on the 3rd postoperative day.DiscussionDiagnosing Spigelian hernia clinically is challenging but radiologic investigations like computed tomography help establish the diagnosis and clarify the contents.ConclusionSpigelian hernia itself is a rare entity and to add to that, herniation of ovary and fallopian tube through Spigelian fascial defect is very rare and a possibility in females.     

Nasotracheal fibreoptic intubation: a randomised controlled trial comparing the GlideRite® (Parker-Flex® Tip) nasal tracheal tube with a standard pre-rotated nasal RAE™ tracheal tube

In a randomised controlled study, we compared the ease of railroading a GlideRite^® nasal tracheal tube over a fibrescope with that of a pre‐rotated RAE? nasal tracheal tube. We studied 110 anaesthetised patients with no known airway difficulties undergoing elective dental or maxillofacial surgery. Impingement was more common with the GlideRite tubes (11/55 (20%)) compared with the pre‐rotated RAE tubes (3/55 (5%); p = 0.02). The median (IQR [range]) time to intubation (GlideRite 7.6 (4.7–10.8 [3.0–46.2]) s; RAE 8.0 (6.2–10.7 [2.4–30.0]) s) and postoperative sore throat numerical ratings (GlideRite 2 (0–3 [0–10]); RAE 2 (0–5 [0–8])) were similar. A 90° anticlockwise pre‐rotation of a standard nasal RAE tube has a higher initial rate of successful railroading at first attempt and is therefore superior to a GlideRite nasotracheal tube during nasal fibreoptic intubation.     

Is a drain tube necessary for minimally invasive lumbar spine fusion surgery?

Purpose

This study aimed to evaluate if closed suction wound drainage is necessary in minimally invasive surgery of transforaminal lumbar interbody fusion (MIS TLIF).

Methods

This is a prospective randomized clinical study. Fifty-six patients who underwent MIS TLIF were randomly divided into groups A (with a closed suction wound drainage) and B (without tube drainage). Surgical duration, intraoperative blood loss, timing of ambulation, length of hospital stay and complications were recorded. Patients were followed up for an average of 25.3 months. Clinical outcome was assessed using the Oswestry disability index and visual analogue scale (VAS). Fusion rate was classified with the Bridwell grading system, based on plain radiograph.

Results

Both groups had similar patient demographics. The use of drains had no significant influence on perioperative parameters including operative time, estimated blood loss, length of stay and complications. Patients in group B started ambulation 1 day earlier than patients in group A (p < 0.001). Clinical outcomes were comparable between group A and group B.

Conclusion

A drain tube can lead to pain, anxiety and discomfort during the postoperative period. We conclude that drain tubes are not necessary for MIS TLIF. Patients without drains had the benefit of earlier ambulation than those with drains.

     

Nephrostomy tube drainage with pyeloplasty: is it necessarily a bad choice?

PURPOSE: Despite continued controversy regarding the optimal method of urinary diversion after dismembered pyeloplasty in children, we have treated the majority of our patients with postoperative nephrostomy tubes and no stents. We report our experience. MATERIALS AND METHODS: The records of all patients who underwent surgery for ureteropelvic junction obstruction from August 1985 to October 1998 and were treated only with a nephrostomy tube after pyeloplasty were reviewed for hospital course, complications and postoperative followup. All patients had a perinephric Penrose drain as well as a Foley catheter placed for bladder drainage. RESULTS: A total of 137 pyeloplasties were performed in 132 patients, including 5 with bilateral ureteropelvic junction obstruction, using only nephrostomy tube drainage with an average followup of 2.1 years. Initial nephrostograms demonstrated good drainage across the repair with no extravasation in 91% of patients. Subsequent nephrostograms revealed a widely patent anastomosis in the remaining cases. No patient had postoperative obstruction, or required secondary pyeloplasty or nephrectomy. Urinary tract infection developed in 2 patients (1.5%). Mean hospitalization was 4.4 days. There was a significant difference in length of stay in the last 5 years compared to that in previous years (3.4 versus 5.8 days, p <0.05) and hospital stay continues to decrease. CONCLUSIONS: Use of only a nephrostomy tube after pyeloplasty resulted in few complications and an open anastomosis in 100% of cases. Nephrostomy drainage not only serves as a protective mechanism, but also allows easy access for radiographic studies before removal of the tube. In addition, nephrostomy tube drainage does not prolong hospitalization and the tube may be easily removed on an outpatient basis without further anesthesia.     

Aortic root remodeling operation: how do we tailor a tube graft?

BACKGROUND: In aortic root remodeling operation, it is difficult to perform graft sizing and tailor a graft appropriately. Thus the aim of this study was to create guidelines for sizing and tailoring that would help to standardize the operation. METHODS: We studied the anatomy of the aortic root and assessed the reliability of three equations reported to assist in graft sizing with aortic root casts obtained from 127 cadavers. RESULTS: Yacoub's equation and ours accurately predicted the diameter at the sinotubular junction. Three cusps of the aortic valve were not equal in size. Sinus height of the aortic root was unpredictable. CONCLUSIONS: Based on these results, we recommend that aortic root remodeling operation should be performed as follows: (1) graft sizing should be performed using Yacoub's way or our way; (2) the tube graft should be cut into three parts in proportion to the size of each cusp; and (3) the position of the commissures in the tube graft should be secured with sutures first, and the depth of the sinuses should be determined later.     

Fiberoptic-guided tracheal tube placement through the air-Q? Intubating Laryngeal Airway: a performance study in a manikin

Purpose  

This study characterizes the performance and success rate for fiberoptic-guided tracheal tube placement through the air-Q^? Intubating Laryngeal Airway (air-Q).     

Gastrostomy tube placement in infants and children: is there a preferred technique?

Purpose

Advances in percutaneous endoscopic gastrostomy (PEG) and laparoscopic (LAP) techniques, including LAP-assisted PEG, offer alternatives to the standard open gastrostomy technique. This study compares the outcomes of the PEG and LAP techniques.

Methods

All gastrostomy tube placements were reviewed at our institution from January 2004 to October 2008. Demographic, procedural, and outcome data were collected. Univariate and logistic regression statistical analysis was performed with SPSS (SPSS, Chicago, IL), and P ≤ .05 considered significant.

Results

Of 238 gastrostomy tubes placed, 134 were PEG (56.3%) and 104 were LAP (43.7%). Most tubes were inserted for failure to thrive (74.4%) and feeding difficulties (52.1%). Patient weight and age were increased and operative time decreased for PEG compared with other methods. Percutaneous endoscopic gastrostomy patients also had a statistically higher number of postoperative complications, requiring a return trip to the operating room (P = .02).

Conclusion

Minimally invasive PEG and LAP techniques have supplanted the open technique for most patients. Operative time for PEG placement is shorter than other methods, and patients chosen for the PEG method of placement are older and of greater weight. However, there were significant and more serious postoperative complications requiring a second operation in the PEG group when compared with the LAP group.     

Laparoscopic vs percutaneous endoscopic gastrostomy tube insertion: a new pediatric gold standard?

Background/Purpose

Gastrostomy tube insertion is frequently performed in children. Percutaneous endoscopic gastrostomy (PEG) insertion, considered by many to be the “gold standard,” is unavoidably associated with a risk of intestinal perforation and frequently requires a second anesthetic for its replacement with a low-profile “button.” We hypothesized that a laparoscopic technique with low-pressure insufflation would yield comparable outcomes, a lower procedural complication rate, and require fewer anesthetics per patient.

Methods

A retrospective review of all surgeon-placed gastrostomy tubes (exclusive of those associated with fundoplication or other procedures) between January 2002 and December 2003 was undertaken. Data collected included type of procedure (PEG vs laparoscopic), indication, patient demographics (including neurologic comorbidity), operative time, complications (procedure-specific and nonspecific), and number of procedural anesthetics to “achieve” a low-profile tube. Groups were compared by univariate and multiple logistic regression analyses.

Results

One hundred nineteen gastrostomy tubes (26 laparoscopic = 21.8%) were inserted. The PEG and laparoscopic gastrostomy groups were comparable from the perspectives of age, size, indications for tube placement, and operative time. The complication rate after PEG placement was significantly higher than after LG (14% vs 7.7%; P = .023), and 72 (77.4%) of PEG patients required a second anesthetic for tube change.

Conclusions

Laparoscopic gastrostomy tube insertion is safe and easy to perform, with outcomes comparable to that of PEG tube insertion. It obviates the need for a second procedural anesthetic and may emerge as the gold standard for gastrostomy tube placement.     

Is there a difference in outcome when treating traumatic intraperitoneal bladder rupture with or without a suprapubic tube?

PURPOSE: Primary bladder repair with a suprapubic tube is considered to be effective for managing intraperitoneal bladder injury. We compared the outcomes of suprapubic tube placement and no suprapubic tube for this injury. MATERIALS AND METHODS: We reviewed the charts of 31 men and 3 women with a mean age of 28.5 years who required emergency operative repair without a cystogram of traumatic bladder injury from 1992 to 1997. Patient characteristics, mechanism of injury, associated injuries, and short and long-term complications were reviewed. RESULTS: Penetrating and blunt trauma occurred in 28 (82%) and 5 (15%) patients, respectively, while 1 had spontaneous bladder rupture. After primary bladder repair the bladder was drained with a suprapubic tube in 18 cases (53%) and a urethral catheter only in 16 (47%). There were no significant differences between the 2 groups with respect to mechanism of injury, patient age, location of injury in the bladder, coexisting medical illnesses, stability in the field or emergency room, or the bladder repair technique. The 18 patients treated with a suprapubic tube had an associated injury that resulted in 2 deaths, while 13 of the 16 treated with urethral catheter drainage only had an associated injury and 1 died. Urological and nonurological complications in the suprapubic tube versus urethral catheter only group developed in 28 and 33 versus 19 and 19% of the cases, respectively (p <0.05). Followup ranged from 1 month to 4 years. No significant long-term morbidity was noted in either group. CONCLUSIONS: These data indicate that intraperitoneal bladder injuries may be equally well managed by primary bladder repair and urethral catheter drainage only versus suprapubic tube drainage.     

Does routine nasogastric tube placement after an operation for perforated appendicitis make a difference?

BACKGROUND: Divergent opinions exist regarding the routine use of nasogastric (NG) tubes in the postoperative management of patients undergoing abdominal surgery. Empiric use of an NG tube after abdominal surgery is presumed to prevent abdominal distension, vomiting, and ileus, which may complicate the postoperative course. To investigate the validity of this assumption, we compared the postoperative course of patients who underwent appendectomy for perforated appendicitis who subsequently either had or did not have an NG tube placed postoperatively. METHODS: A retrospective chart review of all children operated for perforated appendicitis between 1999 and 2004 was performed. Patients with prolonged hospitalizations were excluded to eliminate bias created by patients with multiple operations and opportunities for NG placement. The use of an NG tube, time to first and to full oral feeds, length of hospitalization, and complications were compared between groups. RESULTS: Patients with NG tubes left in place (N = 105) were compared with those who did not receive an NG tube (N = 54) following appendectomy for perforated appendicitis. Mean time to first oral intake was 3.8 d in those with NG tubes compared with 2.2 d in those without NG tubes (P < 0.001). Similarly, mean time to full feeds was 4.9 d when an NG tube was left compared with 3.4 d in those without tubes (P < 0.001). Mean length of stay was 6.0 d in those with NG tubes compared to 5.6 d in those without (P = 0.002). CONCLUSIONS: The use of NG decompression after an operation for perforated appendicitis does not appear to improve the postoperative course and we recommend that it is not routinely used in this patient population.