Angiographic characteristics of ruptured paraclinoid aneurysms: risk factors for rupture

Background

The diagnosis and treatment of unruptured paraclinoid aneurysms has been increasing with the recent advent of diagnostic tools and less invasive endovascular therapeutic options. Considering the low incidence of rupture, investigation of the characteristics of ruptured paraclinoid aneurysm is important to predict rupture risk of the paraclinoid aneurysms. The objective of this study is to evaluate probable factors for rupture by analyzing the characteristics of ruptured paraclinoid aneurysms.

Methods

A total of 2,276 aneurysms (1,419 ruptured and 857 unruptured) were diagnosed and treated endovascularly or microsurgically between 2001 and 2011. Among them, 265 were paraclinoid aneurysms, of which 37 were ruptured. Removing 12 blister-like aneurysms, 25 ruptured and 228 unruptured saccular aneurysms were included and the medical records and radiological images were retrospectively analyzed.

Results

Of 25 aneurysms, 16 (64.0 %) were located in the superior direction. Five were inferior located lesions (20 %) and four were medially located lesions (16.0 %). Laterally located lesions were not found. The mean size of aneurysms was 9.4?±?5.6 mm. Ten aneurysms (40.0 %) were ≥?10 mm in size. Thirteen aneurysms (52.0 %) were lobulated. The superiorly located aneurysms were larger than the other aneurysms (10.3?±?5.8 mm vs. 7.7?±?4.9 mm) and more frequently lobulated (ten of 16 vs. three of nine). In a comparative analysis, the ruptured aneurysms were located more in the superior direction compared with unruptured aneurysms (64 vs. 23.2 %, p?<?0.0001). Large aneurysms (36.0 vs. 7.9 %, p?<?0.0001), longer fundus diameter (mean 9.4?±?5.6 vs. 4.8?±?3.3 mm, p?=?0.001), dome-to-neck ratio (mean 1.8?±?0.9 vs. 1.2?±?0.5, p?<?0.0001), and lobulated shape aneurysms were more likely to be ruptured aneurysms (13 of 25 ruptured aneurysms, 52.0 %, p?=?0.001).

Conclusions

Rupture risk of the paraclinoid aneurysm is very low. However, superiorly located paraclinoid aneurysms appear more likely to rupture than other locations. Angiographically, more conservative indication for the treatment of paraclinoid aneurysm should be recommended except for superior located lesions.     

Psychological state, quality of life, and body composition in postmenopausal women with osteoporosis in Lithuania

Summary

The objective of this study was to determine body composition, physical activity, and psychological state in postmenopausal women with osteoporosis. Fat mass, lean mass, water mass, and basal metabolic rate are lower, self-reported physical activity and risk factors of fractures are higher, and cognitive functions were worse in osteoporotic patients than in controls. Significant correlations were found between physical activity and emotional state parameters.

Introduction

This study aims to determine peculiarities of body composition, physical activity, risk factors predicting fractures, psychological state and quality of life, and possible relations between them in postmenopausal women with osteoporosis in Lithuania.

Methods

Thirty-one postmenopausal women with osteoporosis and 29 healthy age- and sex-matched controls were included in the study. Profile of Mood State and Hospital Anxiety and Depression Scale were used for the assessment of emotional state. Trail Making Test and Digit Symbol Test of Wechsler Adult Intelligence Scale were used to evaluate cognitive functioning. Quality of life was evaluated using the World Health Organization Brief Quality of Life Questionnaire. Risk of fractures was assessed by the Risk Factors Predicting Questionnaire.

Results

Fat mass (22.4?±?4.7 vs. 40.6?±?14.2 kg, p?<?0.001), lean mass (37.3?±?6.0 vs. 48.1?±?7.6 kg, p?<?0.001), water mass (31.6?±?2.9 vs. 38.3?±?5.3 kg, p?<?0.001), and basal metabolic rate (1,253?±?132 vs. 1,456?±?126 kcal, p?<?0.001) were lower in osteoporotic patients than in controls. Self-reported physical activity (2.35?±?0.6 vs. 1.69?±?0.5, p?<?0.001) and risk factors of fractures (5.9?±?2.1 vs. 2.6?±?2.4, p?<?0.001) were higher in women with osteoporosis than in healthy age- and sex-matched controls (2.35?±?0.6 vs. 69?±?0.5, p?<?0.001). Trail making A and B scores were higher in patients than in age- and sex-matched controls (55.8?±?19.9 vs. 45.1?±?19.9, p?=?0.07 and 118.2?±?34.6 vs. 92.8?±?48.7, p?=?0.006). Some significant correlations were detected between physical activity and emotional state and quality of life parameters.

Conclusion

In postmenopausal women with osteoporosis, fat body mass, lean body mass, water body mass, basal metabolic rate, and waist-to-hip ratio are lower, physical activity and risk of fractures are higher, and cognitive functions are worse than in age- and sex-matched controls. Some psychological peculiarities could be related to physical activity in women with osteoporosis.     

Long-Term Outcomes of Laparoscopic Surgery for Advanced Transverse Colon Cancer

Background

The role of laparoscopic surgery for advanced transverse colon cancer (TCC) remains controversial, especially in terms of long-term oncologic outcomes.

Methods

This retrospective cohort study enrolled 157 consecutive patients who underwent curable resections for advanced TCC between January 2002 and June 2011 (laparoscopic-assisted colectomy (LAC), n?=?74; open colectomy (OC), n?=?83). Short-term outcomes and oncologic long-term outcomes were compared between the two groups.

Results

Compared to the OC group, patients in the LAC group had less blood loss (LAC vs. OC, 79.6?±?70.3 vs. 158.4?±?89.3 ml, p?<?0.001), faster return of bowel function (2.6?±?0.7 vs. 3.8?±?0.8 days, p?<?0.001), and shorter postoperative hospital stay (10.3?±?3.7 vs. 12.6?±?6.0 days, p?=?0.007). Conversions were required in four (5.4 %) patients. Rates of short-term complication, mortality, and long-term complication were comparable between the two groups. The median follow-up time was 54 (26–106) months in the LAC group and 58 (29–113) months in the OC group (p?=?0.407). There were no statistical differences in the rates of 5-year overall survival (73.6 vs. 71.1 %, p?=?0.397) and 5-year disease-free survival (70.5 vs. 66.7 %, p?=?0.501) between the two groups.

Conclusions

Laparoscopic surgery for advanced TCC yield short-term benefits while achieving equivalent long-term oncologic outcomes.     

Four-year trends in the treatment of cerebral aneurysms in Poland in 2009-2012

Background

The dilemma concerning the appropriate treatment of the intracranial aneurysms (IAs) has not yet been resolved and still remains under fierce debate. This study refers to the recent trends in the use of and outcomes related to coiling compared with clipping for unruptured and ruptured IAs in Poland over a 4-year period.

Methods

The analysis refers to treatment of IAs performed in Poland between 2009-2012. Patients’ records were cross-matched by ICD-9 codes for ruptured SAH (430) or unruptured cerebral aneurysm (437.3) along with codes for clipping (39.51) and coiling (39.79, 39.72, or 39.52). Multivariable logistic regression was used to compare in-hospital deaths, hospital length of stay (LOS), therapy allocation and aneurysm locations in unruptured vs. ruptured and clipped vs. coiled groups. Differences in the number of procedures between 16 administrative regions were standardized per 100,000 people.

Results

In 2009-2012, 11,051 procedures were identified, including 5,968 ruptured and 5,083 unruptured aneurysms. Overall increase was 2.3 % in clipping and 13.1 % in coiling; a significant trend was found in endovascular procedures (p?=?0.044). Ruptured aneurysms were clipped more frequently (OR?=?1.66;); in unruptured IAs, endovascular procedure was preferred 3.5 times more than clipping. The annual in-hospital mortality was 7.6 % in clipping and 6.7 % in endovascular treatment. LOS was two times longer after clipping in unruptured aneurysms (OR?=?2.013). After the procedures were standardized per 100,000 people, the average for Poland was established as 9.09 in 2009, 10.86 in 2010, 10.55 in 2011, and 11.49 in 2012. This index had the highest values in Mazovia (12.9, 2009; 15.4, 2010; 17.4, 2011; 18.6, 2012.

Conclusions

Data analysis revealed an increase in overall number of IAs treated in Poland between 2009-2012. A significant upward trend of endovascular procedures was found, whereas the number of clipped aneurysms remained relatively steady over the study period.     

Obesity, But Not High-Fat Diet, Promotes Murine Pancreatic Cancer Growth

Background

Obesity accelerates pancreatic cancer growth; the mechanisms underlying this association are poorly understood. This study evaluated the hypothesis that obesity, rather than high-fat diet, is responsible for accelerated pancreatic cancer growth.

Methods

Male C57BL/6J mice were studied after 19?weeks of high-fat (60?% fat; n?=?20) or low-fat (10?% fat; n?=?10) diet and 5?weeks of Pan02 murine pancreatic cancer growth (flank).

Results

By two-way ANOVA, diet did not (p?=?0.58), but body weight, significantly influenced tumor weight (p?=?0.01). Tumor weight correlated positively with body weight (R ²?=?0.562; p?<?0.001). Tumors in overweight mice were twice as large as those growing in lean mice (1.2?±?0.2?g vs. 0.6?±?.01?g, p?<?0.01), had significantly fewer apoptotic cells than those in lean mice (0.8?±?0.4 vs 2.4?±?0.5; p?<?0.05), and greater adipocyte volume (3.7 vs. 2.2?%, p?<?0.05). Apoptosis (R ²?=?0.472; p?=?0.008) and serum adiponectin correlated negatively with tumor weight (R?=?0.45; p?<?0.05).

Conclusions

These data suggest that body weight, and not high-fat diet, is responsible for accelerated murine pancreatic cancer growth observed in this model of diet-induced obesity. Decreased tumor apoptosis appears to play an important mechanistic role in this process. The concept that decreased apoptosis is potentiated by hypoadiponectinemia (seen in obesity) deserves further investigation.     

Endoscopic Duodenal–Jejunal Bypass Liner Rapidly Improves Type 2 Diabetes

Background

Bariatric procedures excluding the proximal small intestine improve glycemic control in type 2 diabetes within days. To gain insight into the mediators involved, we investigated factors regulating glucose homeostasis in patients with type 2 diabetes treated with the novel endoscopic duodenal–jejunal bypass liner (DJBL).

Methods

Seventeen obese patients (BMI 30–50 kg/m²) with type 2 diabetes received the DJBL for 24 weeks. Body weight and type 2 diabetes parameters, including HbA_1c and plasma levels of glucose, insulin, glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), and glucagon, were analyzed after a standard meal before, during, and 1 week after DJBL treatment.

Results

At 24 weeks after implantation, patients had lost 12.7?±?1.3 kg (p?<?0.01), while HbA_1c had improved from 8.4?±?0.2 to 7.0?±?0.2 % (p?<?0.01). Both fasting glucose levels and the postprandial glucose response were decreased at 1 week after implantation and remained decreased at 24 weeks (baseline vs. week 1 vs. week 24: 11.6?±?0.5 vs. 9.0?±?0.5 vs. 8.6?±?0.5 mmol/L and 1,999?±?85 vs. 1,536?±?51 vs. 1,538?±?72 mmol/L/min, both p?<?0.01). In parallel, the glucagon response decreased (23,762?±?4,732 vs. 15,989?±?3,193 vs. 13,1207?±?1,946 pg/mL/min, p?<?0.05) and the GLP-1 response increased (4,440?±?249 vs. 6,407?±?480 vs. 6,008?±?429 pmol/L/min, p?<?0.01). The GIP response was decreased at week 24 (baseline—115,272?±?10,971 vs. week 24—88,499?±?10,971 pg/mL/min, p?<?0.05). Insulin levels did not change significantly. Glycemic control was still improved 1 week after explantation.

Conclusions

The data indicate DJBL to be a promising treatment for obesity and type 2 diabetes, causing rapid improvement of glycemic control paralleled by changes in gut hormones.     

Outcomes of Laparoscopic Sleeve Gastrectomy in Patients Older than 60 Years

Background

Morbidity and mortality following laparoscopic sleeve gastrectomy (LSG) occur at acceptable rates, but its safety and efficacy in the elderly are unknown.

Methods

A retrospective review was performed of all patients aged >60 years who underwent LSG from 2008 to 2012. These patients were 1:2 matched, by gender and body mass index (BMI) to young patients, 18?<?age?<?50. Data analyzed included demographics, preoperative and postoperative BMI, postoperative complications, and improvement or resolution of obesity-related comorbidities.

Results

Fifty-two morbid obese patients older than 60 years underwent LSG (mean age, 62.9?±?0.3 years). These were matched to 104 young patients, age 18–50 years (mean age, 35.7?±?0.8 years). Groups did not differ in male gender (44 vs. 43 %, p?=?0.9), preoperative BMI (42.6?±?0.7 vs. 42.6?±?0.6, p?=?0.97), and length of follow-up (17?±?2 vs. 22?±?1.4 months, p?=?0.06). Obesity-related comorbidities were significantly higher in the older group (96 vs. 65 %, p?<?0.001). Excess weight loss (EWL) was higher in the younger group (75?±?2.4 vs. 62?±?3 %, p?=?0.001). Older patients had a significantly higher rate of a concurrent hiatal hernia repair (23 vs. 1.9 %, p?<?0.001). Overall postoperative minor complication rate was higher in the older group (25 vs. 4.8 %, p?<?0.001). This included atrial fibrillation (9.5 %), urinary tract infection (7 %), trocar site hernia (4 %), dysphagia, surgical site infection, bleeding, bowel obstruction, colitis, and nutritional deficiency (2 %, each). No perioperative mortality occurred. Comorbidity resolution or improvement was comparable between groups (88 vs. 80 %, p?=?0.13).

Conclusions

LSG is safe and very efficient in patients aged >60, despite higher rates of perioperative comorbidities.     

Predictors of thromboembolism during coil embolization in patients with unruptured intracranial aneurysm

Objectives

To identify the incidence of thromboembolic complications based on magnetic resonance imaging (MRI) and to explore the potential risk factors for thromboembolism (TE) during the periprocedural period of elective coil embolization for unruptured intracranial aneurysms.

Methods

We retrospectively reviewed all aneurysm cases treated with coil insertion between January 2008 and March 2011. Two hundred eighty-two coiling procedures for unruptured aneurysms were included in this study. The patients’ demographic characteristics were documented and records reviewed for abnormalities in diffusion-weighted imaging (DWI) seen on post-procedure MRI, intraoperative thrombus formation, and clinical signs of stroke.

Results

Overall, there were 87 (30.9 %) procedure-related complications in 282 aneurysms treated: 2 (0.7 %) procedural ruptures, 5 (1.8 %) symptomatic infarctions, and 80 (28.3 %) asymptomatic infarctions. Thromboembolic events during the procedure were observed more often in the the hyperlipidemia group (32/71 aneurysms, 45.1 %) than in the normal lipid profile group (39/196 aneurysms, 25.6 %; p?=?0.002; chi-squre test). The coiling technique and size of the aneurysm were also associated with TE (p?<?0.001 and p?=?0.004).

Conclusion

Hyperlipidemia seems to be associated with a significant increase in the rate of thromboembolic events. In preventive procedures, modifiable risk factors should be managed to reduce complications. Although permanent deficits are rare, the high rate of thromboembolic events suggests that improvements in the technique, such as the addition of antiplatelet agents and the development of new embolic materials, are necessary.     

Usefulness of an enhanced recovery after surgery protocol for perioperative management following open repair of an abdominal aortic aneurysm

Purpose

To achieve early recovery and early discharge from the hospital by applying an enhanced recovery after surgery (ERAS) protocol, which is mainly used with colonic surgery, for the perioperative management of open AAA surgery.

Method

One hundred twenty-seven open AAA surgery cases successfully carried out between 2003 and 2011 were included in this study. The ERAS protocol was used for the cases from April 2008 onward, and we performed a comparison of the conventionally treated cases with ERAS cases regarding the start of postoperative oral consumption, the postoperative hospital stay, and hospitalization medical costs.

Results

The time to restarting oral consumption and the postoperative hospital stay were significantly shorter for the ERAS group (n?=?52) compared to the conventionally managed group (n?=?75); with values of 59?±?15 and 93?±?25?h (p?=?0.021), 9?±?3 and 16?±?5?days (p?=?0.001), respectively. The medical costs for the ERAS group were 92?% of the costs of the conventionally managed group.

Conclusion

Use of the ERAS protocol for the perioperative management of open AAA surgery shortened the time before recommencing oral consumption, the postoperative hospital stay, and reduced the medical costs compared to the conventional approach.     

The Role of Gender in Primary Hyperparathyroidism: Same Disease, Different Presentation

Background

Hyperparathyroidism is much more common in women and therefore may represent different diseases in men and women. In order to understand the role of gender in hyperparathyroidism, we reviewed our experience.

Methods

We analyzed a prospective database of 1309 consecutive patients with primary hyperparathyroidism who underwent parathyroidectomy at our institution between March 2001 and August 2010.

Results

The female-to-male ratio was 3.3:1, and female patients were older at presentation (60?±?0 vs. 57?±?1?years, p?p?=?0.005) and the most common symptom for men was kidney stones (23?% vs. 13?%, p?p?p?=?0.03), higher parathyroid hormone level (140?±?7 vs. 124?±?4?pg/ml, p?=?0.04), higher urinary calcium level (376?±?10 vs. 314?±?5?mg/24?h, p?p?p?=?0.004). The operative approach as well as the number of glands involved and their location did not significantly differ between the groups. The mean gland weight for a single adenomas was higher in male patients (1123?±?128 vs. 636?±?32?mg, p?=?0.001). No significant difference was identified in the immediate and remote postoperative course.

Conclusions

Hyperparathyroidism appears to present differently depending on gender. Male patients more often present without symptoms, present with vitamin D deficiency, and have larger parathyroid glands. Importantly, surgical outcomes were equivalent between men and women.     

Diagnosis of Diabetes Remission After Bariatic Surgery May be Jeopardized by Remission Criteria and Previous Hypoglycemic Treatment

Background

Controversy exists regarding type 2 diabetes (T2D) remission rates after bariatric surgery (BS) due to heterogeneity in its definition and patients' baseline features. We evaluate T2D remission using recent criteria, according to preoperative characteristics and insulin therapy (IT).

Methods

We performed a retrospective study from a cohort of 657 BS from a single center (2006–2011), of which 141 (57.4 % women) had T2D. We evaluated anthropometric and glucose metabolism parameters before surgery and at 1-year follow-up. T2D remission was defined according to 2009 consensus criteria: HbA1c <6 %, fasting glucose (FG) <100 mg/dL, and absence of pharmacologic treatment. We analyzed diabetes remission according to previous treatment.

Results

Preoperative characteristic were (mean?±?SD): age 53.9?±?9.8 years, BMI 43.7?±?5.6 kg/m², T2D duration 7.4?±?7.6 years, FG 160.0?±?54.6 mg/dL, HbA1c 7.6?±?1.6 %. Fifty-six (39.7 %) individuals had IT. At 1-year follow-up, 74 patients (52.5 %) had diabetes remission. Percentage weight loss (%WL) and percentage excess weight loss (%EWL) were associated to remission (35.5?±?8.1 vs. 30.2?±?9.5 %, p?=?0.001; 73.6?±?18.4 vs. 66.3?±?22.8 %, p?=?0.037, respectively). Duration of diabetes, age, and female sex were associated to nonremission: 10.3?±?9.4 vs. 4.7?±?3.8 years, p?<?0.001; 55.1?±?9.3 vs. 51.2?±?9.9 years, p?=?0.017; 58.9 vs. 33.3 %, p?=?0.004, respectively. Prior treatment revealed differences in remission rates: 67.1 % in case of oral therapy (OT) vs. 30.4 % in IT, p?<?0.001. OR for T2D remission in patients with previous IT, compared to those with only OT, were 0.157–0.327 (p?<?0.05), adjusting by different models.

Conclusions

Consensus criteria reveal lower T2D remission rates after BS than previously reported. Prior insulin use is a main setback for remission.     

Effects of single dose methylprednisolone on patient recovery after cardiopulmonary bypass

Background

Ischaemic reperfusion injury, systemic inflammatory response and multi-organ dysfunction are not infrequent following Cardiopulmonary Bypass (CPB). We investigated the role of methylprednisolone in minimizing this state.

Subject and Methods

Hundred consecutive patients undergoing elective single heart valve replacement surgery were randomized to receive methylprednisolone 30?mg/kg (M group) or placebo (P group) after induction of anaesthesia. Data were analyzed using the??t?? test and Fischer test.

Results

The cardiac indices in the M and P group were 2.79?±?0.13?L/min/m² and 2.52?±?0.26?L/min/m² respectively (p?<?0.0001). The amount of blood loss in the test versus control group was 268.3?±?65.78?ml/24 hours versus 318.7?±?55.5?ml/24?h respectively (p?<?0.0001) and the amount of blood transfused in the test versus control group was 1.26?±?0.57 units versus 1.76?±?0.8 units respectively (p?=?0.005). Patients in the test group had a lower incidence of early postoperative fever and new-onset atrial fibrillation during the first 3?days postoperatively. There was a statistically significant reduction in the intensive care unit stay (3.52?±?1.16?days versus 4.14?±?1.29?days in the M versus P group, p?=?0.01) but not in hospital length of stay (13.7?±?1.78?days versus 14.2?±?1.52?days in the M versus P group, p?=?0.13), or in overall morbidity and mortality.

Conclusions

The use of methylprednisolone prior to initiation of CPB is associated with a more stable postoperative course with a higher cardiac index, shorter duration of Intensive Care Unit (ICU) stay and fewer blood transfusions. Methylprednisolone use also appears to be associated with a lower incidence of early postoperative fever and new-onset atrial fibrillation.     

Evaluating the porcine dermis graft InteXen® in three-compartment transvaginal pelvic organ prolapse repair

Introduction and hypothesis

The aim was to assess the efficacy of three-compartment pelvic organ prolapse (POP) vaginal repair using the InteXen® biocompatible porcine dermal graft as compared to traditional colporrhaphy with sacrospinous ligament suspension.

Methods

Preoperative, operative, postoperative and follow-up data were collected retrospectively. Objective recurrence was defined as POP quantification ≥ stage II and subjective recurrence as a symptomatic bulge.

Results

Each group consisted of 63 patients. Surgery time was longer using InteXen® (72?±?24.5 vs 55?±?23.5 min, p?=?0.0002). Length of hospital stay (4.6?±?1.6 vs 4.9?±?2.1 days, p?=?0.34) as well as duration of follow-up (37.1 vs 35.7 months, p?=?0.45) were equivalent between the two groups. No case of mesh erosion or infection was noted. The objective (17% vs 8%, p?=?0.12) and subjective recurrence rates (13% vs 5%, p?=?0.12) between the two groups were not statistically different.

Conclusions

InteXen® was well tolerated but had similar efficacy to traditional colporrhaphy and sacrospinous ligament suspension.     

Length of stay,costs, and complications in lumbar disc herniation surgery by standard PLIF versus a new dynamic interspinous stabilization technique

Background

The number of lumbar spine surgeries has been increasing during the last 20 years, which also leads to an increase in hospital costs and complications related to surgery. Therefore, there is a greater concern about the costs and safety of the techniques and implants used.

Methods

Patients (aged from 18 to 50 years) presenting with lumbago /sciatica (ICD-10-CM M54.3, M54.4) due to lumbar disc herniation lasting more than 12 weeks, were included. Patients with disc herniation larger than size-2 or size-3 according to the MSU Classification were eligible for participation. Intervention was divided in two groups. In Group 1, patients underwent microdiscectomy and Interspinous Dynamic Stabilization System (IDSS). Meanwhile, in Group 2, patients received discectomy and posterior lumbar interbody fusion (PLIF). The primary outcome measure was the length of stay and costs during hospital admission. We also evaluated several other outcome parameters, including 90- day readmission rate, 90-day complication rate, and re-operations rate. The study was an observational prospective cohort study carried out from January 2015 to August 2016 in which two surgical techniques were compared. Our hypothesis was that a less aggressive procedure, such as discectomy and DSS, will decrease the length of stay and costs, and that it will also reduce the rate of complications with respect to PLIF.

Results

A total of 67 patients (mean age 39.8?±?8.4 years) were included. Patients in the PLIF group had a length of stay increase of 109% (4.52?±?1.76 days vs 2.16?±?1.18 days p?<?0.001) and an in-hospital cost increase of 71% (1821.97?±?460.41€ vs. 1066.20?±?284.34€ p?<?0.001). The reduction of one day of stay is equivalent to a reduction of total in-hospital costs of 12.5%. Patients in the IDSS cohort had no significant differences regarding PLIF cohort in the 90-day readmission rate (12.9% vs 11.1% € p?>?0.999, respectively), 90-day re-operation rate (12.9% vs 11.1% € p?>?0.999) and 90-day complication rates (35.5% vs 52.8% € p?>?0.156). Dural tear and urinary tract infection rates were higher in the PLIF cohort (13.9% vs 3.2%. p?=?0.205 and 11.1% vs 0% p?=?0.118, respectively). Implant related complications were the most frequent in both IDSS and PLIF groups (32.3% vs 38.9% p?=?0.572).

Conclusions

Patients who underwent IDSS had a significant decrease of the length of stay and costs in relation to PLIF group. No significant differences were found in 90-day readmission and reintervention rates for both groups. Although differences were not significant, dural tear and urinary tract infection rates were lower in the interspinous group. IDSS or PLIF after discectomy, did not protect against subsequent 90-day re-operation or readmission compared to discectomy alone.

     

Laparoscopic appendectomy as a teaching procedure: experiences with 1197 patients in a community hospital

Purpose

Since laparoscopic procedures have become more common, resident surgeons have to learn complex laparoscopic skills at an early stage of their career. The aim of this study was to compare the short-term clinical outcome parameters of laparoscopic appendectomy (LA) performed by resident surgeons (RS) or attending surgeons (AS).

Methods

A total of 1197 LA and 57 open appendectomies were performed in a Swiss community hospital between 1999 and 2009. RS performed 684 operations. Parameters including the duration of the operation and hospital stay, intraoperative complications, surgical reinterventions, and a 30-day morbidity and mortality were observed.

Results

The mean age of the patients was 35.6?±?18.17?years. The duration of the operation was longer (61.34?±?25.73?min [RS] vs. 53.65?±?29.89 [AS]?min; p?=?0.0001), but the hospital stay was shorter, in patients treated by RS (3.92?±?2.61?days [RS] vs. 4.87?±?3.23 [AS]?days; p?=?0.0001). The rate of intraoperative complications was not significantly different between the two groups (1.02?% [RS] vs. 0.8?% [AS]; p?=?0.6). The need for surgical reintervention (0.6?% [RS] vs. 2.5?% [AS]; p?=?0.005) and the 30-day morbidity were higher in patients treated by AS (3.7?% [AS] vs. 1.8?% [RS]; p?=?0.04). There was no postoperative mortality.

Conclusions

Under appropriate supervision, surgical residents are able to perform LA with results comparable to those of experienced surgeons.     

Colorectal Surgery After Kidney Transplantation: Characteristics of Early vs. Late Posttransplant Interventions

Background

The majority of colorectal complications after kidney transplantation reportedly occur <1 year of transplant. We aimed to identify differences in complications in the early and late posttransplant period.

Methods

We retrospectively reviewed kidney transplant recipients undergoing colorectal resection from 1 June 2000 to 1 June 2012 at a single institution, comparing patients by posttransplant year (<1 vs. >1 year). Measured outcomes included major complications, postoperative length of stay, perioperative mortality, reoperations, and readmissions.

Results

We identified 45 patients aged 31–77 (median 55). Gastrointestinal malignancy (31 %), diverticular disease (24 %), and ischemic colitis (16 %) were the most common indications for surgery. The early group (n?=?9) had more cases of ischemic colitis (44 vs. 6 %, p?=?0.01), emergent operations (100 vs. 33 %, p?=?0.0003), blood transfusion (78 vs. 31 %, p?=?0.02), longer length of stay (23.2?±?12 vs. 11.7?±?10 days, p?=?0.02), and higher mortality rate (33 vs. 6 %, p?=?0.05 compared to the late group (n?=?36)). There were no significant differences in major complications, reoperations, or readmissions.

Conclusions

Kidney transplant recipients undergoing colorectal resection <1 year of transplant have a higher incidence of emergency surgery and ischemic colitis compared with those with >1 year posttransplant. Despite these findings, patients with grafts <1 year had a similar postoperative complication rate to patients with grafts >1 year.     

The Relationships Between IGF-1 and CRP, NO, Leptin, and Adiponectin During Weight Loss in the Morbidly Obese

Background

The relationship between C-reactive protein (CRP), nitric oxide (NO), leptin, adiponectin, and insulin growth factor 1 (IGF-1) is poorly defined in morbidly obese patients before and after gastric bypass and, in some cases, is controversial.

Methods

We examined the plasma of 34 morbidly obese patients before and 1, 6, and 12 months after Roux-en-Y gastric bypass surgery.

Results

Obese people had more CRP (21.3?±?1.8 μg/ml) and leptin (36.9?±?4.0 ng/ml) than those in the control group (nonobese people: CRP?= 6.9?±?0.9 μg/ml, p?<?0.0001; leptin?= 7.5?±?0.4 ng/ml, p?<?0.0001). However, they had less NO (30.4?±?2.7 nmol/ml), IGF-1 (77.5?±?6.6 ng/ml), and adiponectin (11.1?±?1.0 μg/ml) than those in the control group (NO?= 45.8?±?3.9 nmol/ml, p?=?0.0059; IGF-1?= 202.0?±?12.0 ng/ml, p?<?0.0001; adiponectin?= 18.0?±?2.0 μg/ml, p?<?0.0001). During weight loss, the amount of CRP and leptin decreased until they reached the nonobese values, but the level of NO remained lower than in nonobese people, even 1 year after surgery. The linear regression slopes were negative and very significant for leptin (p?=?0.0005) and CRP (p?=?0.0018) but were less significant for NO (p?=?0.0221). IGF-1 displayed a very good linear regression (both negative and significant) with some anthropometric parameters, including body mass index (p?=?0.0025), total fat (p?=?0.0177), and the percentage of fat (p?<?0.0001).

Conclusion

For the first time, we report the relationship between IGF-1 and CRP, NO, leptin, and adiponectin. For all these parameters, the best and most widely demonstrated improvements in comorbidities before and during weight loss in morbid obesity were associated with CRP and leptin.     

The Impact of Preoperative Weight Loss Before Laparoscopic Gastric Bypass

Background

The impact of preoperative weight loss on outcomes following laparoscopic Roux-en-Y gastric bypass (LRYGB) is a controversial issue. We evaluated our outcomes of LRYGB in patients who lost different amount of weight prior to surgery.

Methods

Patients who underwent primary LRYGB were divided in three groups on the basis of preoperative weight loss percentage. Group A comprised 166 patients, who lost <5 % of their weight preoperatively; group B comprised 239 patients who lost >5 to 10 % and group C included 143 patients who lost >10 %. Intra- and postoperative complications at 30 days, hospital stay, and outcomes were evaluated.

Results

Significant difference was found in operative (mean ± SD) time [104.43?±?36.40 min in group A, 80.08?±?23.07 min in group B, and 76.99?±?23.23 min in group C; p?<?0.001 in group A versus group B or group C; p?=?0.210 in group B versus group C]. Difference in hospital stay was significant (3.33?±?3.22 days in group A, 2.10?±?2.77 in group B, and 1.87?±?1.44 in group C; p?<?0.001 in group A versus groups B or C). Overall postoperative morbidity rate was 33.13 % in group A, 19.25 % in group B, and 11.89 % in group C, with significant difference in group A versus groups B or C (p?=?0.002 and p?<?0.001). Mean excess weight loss was significantly higher (72.7 %) in group C versus group A (63.1 %) (p?=?0.015) at 12 months.

Conclusions

Weight loss >5 % prior to LRYGB may reduce morbidity, and preoperative weight loss >10 % may improve weight loss outcomes at 1-year follow-up.     

Laparoscopic cholecystectomy—comparison of early postoperative results in an Australian rural centre and a German university hospital

Background

Laparoscopic cholecystectomy is the treatment of choice for symptomatic gallstone disease. Cultural as well as organisational differences can result in significant variations of postoperative length of stay.

Aim of the present study

The aim of this study is to evaluate whether differences in postoperative length of stay and early postoperative outcome can be observed by comparison of an Australian rural centre and a German university hospital.

Results

Between February 2006 and August 2007 (18 months), 359 patients (140 Australia, 219 Germany) underwent laparoscopic cholecystectomy. Mean patient age was 50.4?±?1.5 and 53.5?±?1.0 years, respectively. Seventy-seven percent of the Australian and 62% of the German patients were female. Twenty-one percent and 20% of the procedures were emergencies, respectively. Median American Society of Anaesthesiologists score of all patients was two. The conversion rate was 8% in both centres. A 4% complication rate was observed in Australia (N?=?5, 3× bile leak, 1× postoperative bleeding and 1× wound infection) as opposed to 3% in Germany (N?=?7, 2× bile leak, 2× postoperative bleeding and 3× wound infection). Postoperative length of stay in Australia was 1.8?±?0.1 days (median 1 day) and was significantly longer in patients after emergency surgery (1.6?±?0.1 versus 2.6?±?0.3 days, p?<?0.018). Postoperative length of stay in Germany was 3.7?±?0.2 days (median 3 days), and no significant differences were observed when elective and emergency procedures were compared (3.5?±?0.2 versus 3.9?±?0.5 days, p?>?0.05). Comparison of treatment results indicates a significantly shorter postoperative stay in Australia (3 days versus 1 day, p?<?0.001).

Discussion/conclusion

In rural Australia, a median postoperative stay of 1 day after laparoscopic cholecystectomy can be safely achieved. Postoperative length of stay is significantly longer in the German setting with otherwise comparable patients and surgical techniques. Simple changes of pre- and postoperative management of elective as well as emergency laparoscopic cholecystectomy will allow, for substantial cost savings, for the German health system.