Is laparoscopic cholecystectomy safe and acceptable as a day case procedure?

BACKGROUND: This study reviewed the results of performing day case laparoscopic cholecystectomy to assess the feasibility and safety of the procedure as a day case. MATERIALS AND METHODS: This is a prospective study of 150 day case laparoscopic cholecystectomies performed between September 1999 and December 2004 under the care of the senior author. The results of a follow-up questionnaire to assess post-discharge clinical course and patient satisfaction were analyzed. All patients had commenced eating and drinking and were fully mobile before discharge home. The length of hospital stay was 4-8 hours. RESULTS: The mean age of the patients was 43 years; 134 patients had an American Society of Anesthesiologists grade I, the remaining 16 patients were grade II. The mean operative time was 41 minutes. There were no conversions to open procedures. There was no bleeding, no visceral injury, and no mortality. There was one admission directly from the day surgical unit (admission rate of 0.6%), but no readmission following discharge. No patients were admitted due to postoperative nausea or pain. Ninety-nine (66%) of 150 patients responded to our questionnaire: 97% were satisfied about the information they had received. Patients rated their satisfaction with the procedure as follows: 75% excellent, 21% good, 3% satisfied, and 1 patient un-satisfied. Ninety-four percent of the patients would recommend the procedure as a day case. CONCLUSION: Day case laparoscopic cholecystectomy is safe, feasible, and cost-effective when patients are carefully selected. It provides good patient satisfaction.     

Use of the tourniquet in reconstructive surgery in patients with previous ipsilateral lower extremity revascularization: is it safe? A survey

Tourniquet use in the previously revascularized ipsilateral lower extremity varies among micro-reconstructive surgeons due to the possible complication of graft failure. Examination of evidence-based literature and a current standard of care is needed to establish guidelines for such tourniquet use. Surveys were sent to vascular surgery program directors of ACGME-accredited residency programs to assess prevailing tourniquet use instruction. The survey addressed issues, including tourniquet use in previous bypass surgery, previous angioplasty, and location relative to graft anatomy. Twenty-eight responses were received out of 87 surveys sent (32 percent response rate). Ninety-three percent considered tourniquet use inappropriate in the ipsilateral lower extremity with previous revascularization. Seventy-one percent indicated tourniquet use inappropriate in previous ipsilateral angioplasty. Sixty-one percent regarded graft conduit type to be important in tourniquet use. There remains a lack of prospective, randomized, controlled studies determining risks of occlusion and other complications to the preexisting bypass graft during tourniquet use. Until such studies are done, this survey recommends avoiding tourniquet use in this patient population.     

Day case ankle arthroplasty: are they safe and cost effective? A single-centre case-control study

BackgroundMost patients who have an ankle replacement in the United Kingdom stay in hospital for 2–4 days. This study looked at the safety & cost-effectiveness of a day case ankle replacement pathway.MethodsThis was a retrospective case-control study looking at day case pathway for ankle replacements set up in collaboration with anaesthetists, nurses and physiotherapists. Patients practiced mobilization with crutches before surgery. Patients were discharged home with enough analgesia, and reviewed within 2–5 days of discharge.ResultsTwenty ankle replacements done between November 2017 and November 2019 were reviewed with a mean follow up of 38.4 months. None of these patients required to be readmitted within the first 28 days. No complications were related to the surgery being done as day case. Except one, all patients described the experience as excellent or good.ConclusionPer case the cost savings are estimated to be £880 in comparison to 20 matched inpatient ankle replacements. We conclude that ankle replacements can be safely carried out as day case with appropriate patient selection, pre-operative education and a multi-disciplinary approach.     

Carotid-carotid crossover bypass: is it a durable procedure?

PURPOSE: Reconstruction of a diseased common carotid artery may necessitate direct repair via aortic artery-based revascularization. However, carotid-carotid artery crossover grafting is an alternative extra-anatomic option that obviates the need for median sternotomy. We analyzed our results with carotid-carotid artery crossover bypass surgery. METHODS: Data were analyzed for all patients undergoing carotid-carotid crossover bypass surgery from 1995 to 2000. Data on patient demographics, indications for surgery, perioperative morbidity and mortality, and graft patency were retrieved from a vascular surgery data base and hospital records. Stroke-free survival and graft patency were determined with life table methods. RESULTS: Over 5 years, 24 carotid-carotid artery crossover bypass procedures were performed to treat both symptomatic (n = 19, 79%) and asymptomatic (n = 5, 17%) disease. Nine procedures (38%) were performed in men, 3 (13%) in patients with diabetes, 12 (50%) in active smokers, and 2 in patients with a history of Takayasu arteritis. Patient mean age was 63 years (range, 38-79 years). Twenty-three patients (96%) received polytetrafluoroethylene conduit grafts, and the remaining patients received vein grafts. Ten (42%) patients underwent concomitant endarterectomy. There were no perioperative deaths. One patient (4%) had asymptomatic early occlusion, one had transient neurologic deficit (4%), one (4%) required additional surgery because of bleeding, and one (4%) had a perioperative cerebrovascular accident (stroke). Three (17%) asymptomatic late occlusions were identified at 11, 57, and 64 months, respectively. Mean follow-up was 30 months (range, 1-70 months). Primary patency was 88%, and secondary patency was 92% at 3 years. Stroke-free survival was 94% at 4 years. CONCLUSION: Carotid-carotid artery crossover bypass surgery is a safe and durable procedure. Its use precludes the need for median sternotomy and provides acceptable stroke-free survival.     

Masquelet’s procedure and bone morphogenetic protein in congenital pseudarthrosis of the tibia in children: a case series and meta-analysis

Purpose

A type 2 recombinant human bone morphogenetic protein (rhBMP2) and Masquelet’s procedure were used in three children presenting with congenital pseudarthrosis of the tibia (CPT). Recent studies on CPT suggested the presence in situ of pathologic tissues promoting pseudarthrosis. The authors hypothesized that large segmental resection of pseudarthrosis could improve prognosis of the CPT. Masquelet’s procedure and rhBMP2 have been advocated for the treatment of long bone defect.

Method

The authors report three cases of CPT in children treated with Masquelet’s procedure and application of rhBMP2. They analyzed all published cases of CPT similarly treated.

Results

In the present study, Masquelet’s procedure did not improve the results in the treatment of CPT, but segmental bone reconstruction was possible. Bone healing was obtained in three out of the five applications of rhBMP2. In one case, the patient’s parents asked for leg amputation. Analysis of the 33 published cases with the application of BMP in CPT points to a 62 % healing rate in this pathology.

Conclusion

The authors confirmed that segmental bone reconstruction is possible in CPT using Masquelet’s procedure. In the literature, the success rate of the application of rhBMP in CPT appears to be lower than the healing rate usually reported without BMP. Nevertheless, the strict selection of patients, limited number of cases, and their heterogeneity make interpreting the results difficult. However, the theoretical risk which the children are exposed to during the use of BMP makes rigorous selection of the indications necessary. Finally, the interest of rhBMP2 application in Masquelet’s procedure remained to be proven.     

Is extracorporeal shock wave lithotripsy in pediatrics a safe procedure?

Removal of urinary calculi is an essential element in the successful treatment of patients with urinary stone disease. The new generation of lithotriptors allows the treatment without the need for general anesthesia. The patients, often outpatients, have a faster discharge from the hospital with a reduction of hospitalization time and operating costs. Shock wave lithotripsy (SWL) is currently considered a safe technique for treatment of pediatric urinary lithiasias, with a low percentage of complications and subsequent surgical retreatments. But can we define SWL as a safe procedure in pediatrics? Herein, we will review the literature to justify SWL safety in children, focusing on important parameters as the insertion of preoperative stenting, side effects, and complications after the procedure.     

Hemodilution and anemia in patients with cardiac disease: what is the safe limit?

PURPOSE OF THE REVIEW: Anemia is associated with increased perioperative morbidity and mortality, especially in patients with cardiovascular disease. Although blood transfusions are commonly used in these patients, there is little evidence that such an approach improved patients' clinical outcome. RECENT FINDINGS: From an experimental point of view, tolerance to acute anemia is significantly reduced in animals with externally applied coronary artery stenosis. In rats subjected to transient coronary occlusion, however, moderate isovolemic hemodilution attenuated myocardial damage and improved survival. Tolerance to severe anemia could also be improved by hyperoxic ventilation and maintenance of adequate coronary perfusion pressure. From the clinical perspective, tolerance to anemia in patients with cardiovascular disease closely depends on myocardial oxygen demand, in particular on the level of heart rate. A reduction in heart rate as observed in anesthetized patients undergoing moderate hemodilution may confer some cardioprotection. SUMMARY: The absolute lowest threshold for anemia in patients with cardiac disease cannot be established. Further studies are needed to develop evidence-based transfusion guidelines for these patients. Rather than primarily focusing on transfusion, physicians should first administer therapies that have been shown to improve outcome. In the setting of coronary artery disease, control of heart rate appears of paramount importance.     

Invasive fungal infection in immunocompetent trauma patients – A case series

Zygomycosis is the third leading cause of invasive fungal infection after candidiasis and aspergillosis. Although zygomycosis mostly affects immunocompromised individuals trauma may potentiate infection in immunocompetent individuals. The mortality rate of Zygomycosis is around 50% due to angioinvasion. Here we report a series of 5 cases of angio invasive fungal infection in immunocompetent individuals who sustained trauma in urban areas, out of which only one patient survived following high above knee amputation.     

Is decompressive surgery the only treatment option? A case series of patients with spinal tuberculosis in advanced pregnancy

Purpose

To present cases of spinal tuberculosis in advanced pregnancy treated on anti-tuberculous drug regimen with successful outcome and proposing alternative paradigm to surgical decompression. A case series of five patients in stages of advanced pregnancy with neurologic deterioration and spinal tuberculosis were reported and treated.

Methods

Five patients with backache in advanced stages of pregnancy were reported. Patients were diagnosed as cases of spinal tuberculosis on further imaging studies. Patients were treated and followed up till complete clinical and radiological recovery.

Results

Four out of five patients were treated conservatively on ATT and rest. One patient underwent decompression without instrumentation. All patients recovered neurologically. There were foetal complications in two cases with foetal demise. One patient who underwent surgical decompression had preterm labour with still birth, apparently due to adverse reactions with anaesthetic drugs.

Conclusion

Spinal tuberculosis in pregnancy is a rare occurrence. Hesitation in performing radiographs complicates the outcome with delay in diagnosis and neurological compromise. There are no clear guidelines for treatment of such cases. Conservative treatment with ATT in pregnant patients may be a viable approach. Neurological compromise does not mandate surgical decompression, which in itself is not devoid of complications. Concern of foetal complications is high in surgical treatment.

     

Bisphosphonate-associated peri-implant fractures: a new clinical entity?: A series of 10 patients with 11 fractures

Background and purpose

The current definition of atypical femoral fractures (AFFs) associated with bisphosphonate use includes only de novo fractures. However, in recent years reports of bisphosphonate-associated periprosthetic fractures involving stemmed arthroplasty implants have emerged. In a case series of peri-implant fractures in femurs with plate/screw constructs, we aimed to assess similarities with classical AFFs and how their location may have implications for the pathogenesis and management of AFFs.

Patients and methods

We retrospectively identified 10 patients with 11 peri-implant fractures.

Results

The patients were ambulant women, mean age 80 (70–92) years. Mean duration of bisphosphonate use was 5 (1–10) years. The peri-implant fractures were sustained an average of 4 years (6 months to 9 years) from the time of index surgery. They were all associated with low-energy mechanisms. 8 fractures occurred near the tip of a plate, while 3 traversed the penultimate screwhole of a plate. The peri-implant fractures showed clinical and radiological features of atypicality such as lateral cortical thickening, simple fracture pattern, and lack of comminution. The patients underwent revision surgery, with bone grafting used in all but 1 case. Radiological union was evident after 2–4 months.

Interpretation

Atypical peri-implant fractures of the femur associated with bisphosphonate use may be a new entity. Stress lesions and atypical fractures may tend to develop over stress risers along the operated femur. This finding has implications for the pathogenesis and clinical management of AFFs.Bisphosphonates form the cornerstone of antiresorptive therapy in the management of post-menopausal osteoporosis. They are used in the treatment of malignant and osteoclast-mediated metabolic bone disease. Their use in patients who have undergone total joint arthroplasty of the lower limb is associated with higher periprosthetic bone mineral density and longer implant survival (Bhandari et al. 2005). Bisphosphonates exert their therapeutic effect by reducing bone turnover and increasing overall mineralization. This translates to increased bone mineral density and bone strength, corresponding clinically to reduced risk of vertebral and non-vertebral fragility fractures (Black et al. 1996).In recent years, several published reports have described atypical femoral fractures (AFFs) of the proximal femoral diaphysis and subtrochanteric region, in association with bisphosphonate use (Goh et al. 2007, Neviaser et al. 2008, Isaacs et al. 2010). Bisphosphonates are associated with a higher age-adjusted relative risk of AFF in women than in men, which is higher in alendronate users than in risedronate users (Schilcher et al. 2015). Bisphosphonates may cause changes in bone matrix composition and bone mechanical properties, increasing the propensity for accumulation of microdamage. Impaired target remodeling would contribute to the progression of macrocracks. High interfragmentary strain from physiological loads at a thin fracture line may be a mechanical factor in lack of bone healing (Aspenberg et al. 2010).Periprosthetic/peri-implant fractures are currently excluded from the definition of AFFs. We suggest that peri-implant fractures of the femur with features of atypicality may be linked to bisphosphonate use and that they should be recognized as a clinical entity.     

Pre‐ and postoperative magnetic resonance imaging (MRI) findings in patients treated with laparoscopic sacrocolpopexy. Is it a safe procedure for all patients?

Introduction

Laparoscopic sacrocolpopexy (LSCP) is a reference operation for apical compartment prolapse repair. Aim of this study is to describe the early and midterm postoperative MRI findings of the lumbosacral region (LSR) in patients undergoing LSCP and to detect any imaging changes that the presence of the mesh may cause on patients with preexisting degenerative disease of the LSR.

Methods

Patients with POP‐Q grade III and IV uterovaginal or vaginal vault prolapse who were considered eligible for LSCP were invited to participate. An MRI of the LSR was performed preoperatively and then 3 and 12 months postoperatively. Patients with vaginal vault prolapse underwent LSCP, while women with uterovaginal prolapse were treated with the vaginally assisted laparoscopic sacrocolpopexy (VALS).

Results

A total of 30 patients were included in the study; 18 (60%) underwent LSCP and 12 (40%) VALS. On preoperative MRIs, 83.3% (25/30) of patients had degenerative changes and 70% (21/30) reported having low back pain (LBP). Postoperative MRIs did not reveal any imaging changes compared to the preoperative MRI findings both for patients with or without preexisting degenerative abnormalities of the LSR. No significant changes in the LBP score were observed postoperatively.

Conclusions

Any bone marrow or soft‐tissue changes at MRIs of the LSR early after the insertion of a synthetic mesh, does not constitute an expected postoperative finding and should raise the suspicion of an ongoing inflammatory or infectious spinal process (spondylodiscitis). Additionally, LSCP seems to be a safe surgical approach for women with preexisting degenerative disease of the LSR.