A magnetic resonance imaging analysis of the infraclavicular region: can brachial plexus depth be estimated before needle insertion?

In this study we examined the anatomy of the infraclavicular region to assess the possibility of estimating brachial plexus depth before performing an infraclavicular block, by using readily identifiable landmarks such as the coracoid process (CP) and the clavicle (CL). Four parasagittal planes across the infraclavicular region were analyzed in 21 individual series of magnetic resonance imaging studies. Measurements included distance to the plexus from the skin of the anterior chest wall, position of the plexus relative to the CL, and clavicular width. The brachial plexus is located directly below the CL in the parasagittal plane 1 cm medial to the CP. If one inserts a needle in this same plane at a point in line with the inferomedial edge of the CP, then plexus depth can be estimated as follows. If the needle is raised, as a whole, straight up from the planned point of insertion to be level with the top of the CL, then the distance from the tip of the needle to a point midway across the width of the CL is equivalent to the distance from the insertion point to the plexus. Furthermore, not only is it uncommon to find the lung in this same parasagittal plane, but when it does appear, it is well behind the plexus. Estimating plexus depth, or "depth gauging," in the infraclavicular region is achievable and is a potentially useful strategy. Further study is required to confirm this finding in the clinical environment.     

Third bariatric procedure for insufficient weight loss or weight regain: how far should we go?

BackgroundRevisional procedures in bariatric surgery are increasing with several debated failure risk factors, such as super obesity and old age. No study has yet evaluated the outcomes and risks of a third bariatric procedure indicated for weight loss failure or weight regain.ObjectivesTo assess failure risks of a third bariatric procedure according to Reinhold’s criteria (percentage excess weight loss [%EWL] ≤50% and/or body mass index [BMI] ≥35 kg/m²).SettingA university-affiliated tertiary care center, France.MethodsFrom 2009 to 2019, clinical data and weight loss results of patients who benefited from 3 bariatric procedures for weight loss failure or weight regain were collected prospectively and analyzed using a binary logistic regression. Weight loss failure was defined according to Reinhold’s criteria.ResultsAmong 1401 bariatric procedures performed, 336 patients benefited from 2 or more procedures, and 45 had a third surgery. Eleven patients that were reoperated on because of malnutrition or gastroesophageal reflux disease were excluded from the final analysis. Among 34 patients with 3 procedures because of weight loss failure or regain, mean BMI was 48.3 ± 8.3 kg/m², and mean age was 30 ± 10.7 years. Three out of 34 patients (9%) presented a severe complication (Dindo-Clavien IIIb) and 2 (6%) had a minor one. Achieving Reinhold’s weight loss criteria after the second bariatric procedure was a significant predictor of success of the third procedure (β = 2.9 ± 1.3 S.E.).ConclusionNot reaching Reinhold’s criteria after a second bariatric procedure was identified as a significant risk factor of failure of a third procedure. A third surgery should be carefully discussed especially in case of primary failure of previous procedures.     

Prenatal diagnosis of congenital diaphragmatic hernia: how should the babies be delivered?

Congenital diaphragmatic hernia (CDH) in many patients is diagnosed in utero. In these patients, the delivery can be planned as an elective cesarean, induced vaginal, or spontaneous vaginal delivery. The optimal method has yet to be determined.The aim of this study was to compare the outcome of patients with CDH delivered by different methods.

Methods

The Congenital Diaphragmatic Hernia Study Group was formed in 1995 to compile data on liveborn babies with CDH. Beginning in 2001, data concerning delivery were collected. By October 2005, delivery data were available on 1039 term and near-term infants without cardiac malformations. Five hundred forty-eight had a prenatal diagnosis and complete data on delivery (194 delivered by elective cesarean delivery, 121 by induced vaginal delivery, and 233 by spontaneous vaginal delivery). Patients delivered by a nonelective cesarean delivery were assigned to the delivery group for which they were originally planned.

Results

The overall survival among the 548 patients was 69%. It was highest in patients delivered by cesarean delivery (71%) followed by those delivered through induced vaginal delivery (70%) and spontaneous vaginal delivery (67%). The difference was not statistically significant.Fifty-three percent of all patients survived without extracorporeal membrane oxygenation (ECMO). This was significantly higher after cesarean delivery (60%) than after induced vaginal delivery (49%) or spontaneous vaginal delivery (49%) (P < .05).At 30 days of age, 45% of the patients delivered by cesarean delivery had survived and were on room air. This was slightly lower after induced vaginal delivery (37%) or after spontaneous vaginal delivery (37%), although not statistically significant.

Conclusion

Cesarean delivery was associated with a slightly better outcome in terms of a significantly higher survival without the use of extracorporeal membrane oxygenation, although there was no significant difference in total survival. Because this study was not randomized, it is not possible to determine if the elective cesarean delivery was the cause for the better outcome or if centers favoring elective cesarean delivery by protocol are more skillful in the management of patients with CDH. Mode of delivery for term and near-term infants with CDH deserves further prospective study.     

Long-term outcome of endopyelotomy for the treatment of ureteropelvic junction obstruction: how long should patients be followed up?

PURPOSE: To evaluate the long-term success rate of endopyelotomy for the treatment of ureteropelvic junction (UPJ) obstruction. PATIENTS AND METHODS: Between January 1995 and December 2003, 85 endopyelotomies (10 percutaneous, 75 retrograde) were performed in 77 patients with a mean age of 35.2 +/- 13.9 years. The mean number of procedures per patient was 1.14, with 69 patients undergoing a single procedure. Endopyelotomies were performed using either a cold knife (N = 26), Ho:YAG laser (N = 47), or hook electrode (N = 12). Treatment success was defined as symptomatic relief with radiographic resolution or stabilization of renal function, as judged by an excretory urogram or diuretic renogram. Kaplan-Meier analysis was used to determine the long-term probability of success. RESULTS: With a median follow-up of 37.3 months (range 3-98 months), the overall success rate was 67.5%, and the median time to failure was 7.7 months (range 1-50 months). Kaplan-Meier estimates of success were 87.8% at 6 months, 76.9% at 12 months, 72.2% at 18 months, 68.7% at 24 months, 64.8% at 36 months, and 61.6% at 60 months. The success rate was not significantly affected by the etiology, surgical approach, or incisional method. Similarly, the degree of preoperative hydronephrosis or renal function did not affect the success rate. CONCLUSIONS: The success rate of endopyelotomy decreases as the follow-up increases. Although most failures were detected within 1 year of the procedure, it appears that follow-up of at least 36 months is required for patients who have undergone endopyelotomy for UPJ obstruction.     

Epidural fentanyl and caesarean section: when should fentanyl be given?

Epidural fentanyl is often added to epidural local anaesthetic agents to improve the quality of anaesthesia obtained during Caesarean section. Fentanyl may be given either before or after delivery of the infant. When given before delivery, fentanyl has not been reported to cause neonatal depression, although this remains a concern. A prospective, randomized, double-blind study was undertaken to determine if fentanyl was more effective if given before or after delivery of the baby in 64 women undergoing Caesarean section under lidocaine epidural anaesthesia. Maternal outcome was determined by time to achieve T4 neural blockade, the dose of lidocaine necessary to achieve this block and intraoperative scores for pain, nausea, vomiting, shivering, and sedation. Neonates were assessed by umbilical arterial blood pH and Apgar scores. No differences were detected in either group with respect to maternal or neonatal outcome. We recommend using only epidural local anaesthetic agents before delivery, and giving epidural fentanyl following delivery of the infant.     

How far should partial nephrectomy be extended for renal cell carcinoma?

Conservative renal surgery for cancer has now achieved consensus for imperative, relative, and elective indications (tumor < 4 cm with healthy contralateral kidney). The results show 90%-100% 10-year survival rates and 0%-3% recurrence rates. Surgical techniques are improving and complication rates are decreasing with experience. It is now recognized that margin thickness has no real significance provided that it is negative, even if excision is flush with the tumor capsule. Finally, the frequently cited multifocal lesions are no longer an argument against conservative surgery. The usual limitations of conservative surgery are the size and location of the tumor. Nevertheless, there is no statistically significant difference in the survival and recurrence rates between T1a (< 4 cm) and T1b (4-7 cm) tumors, even if the risk of renal sinus fat tissue involvement increases proportionally with tumor size. Finally, resecting tumors of the renal sinus is possible without adding to the risk of metastasis but increases the risk of surgical complications. The risk of deteriorated renal function with radical nephrectomy is now well documented. Laparoscopy, which has become the reference treatment mode for radical nephrectomy, remains reserved for conservative surgery for exophytic tumors less than 3-4 cm because of the technical difficulties involved in resection and hemostasis. Although conservative surgery is now recognized, extending its indications to tumors greater than 4 cm or in cases of parenchymatous location is supported by real arguments that need to be confirmed. The limit remains the surgical feasibility.     

Carpal tunnel decompression: should the tourniquet be released before or after closure?

Carpal tunnel decompression is a procedure commonly performed by many orthopaedic surgeons. Although there is no general consensus on the best technique in terms of acceptability to patients and operative outcome, some surgeons have a specific personal preference, in particular with regard to the use of a tourniquet and the timing of its release. A prospective randomised controlled trial was performed to determine whether or not deflation of the tourniquet and achieving haemostasis prior to wound closure influenced the outcome of carpal tunnel decompression under local anaesthesia. After division of the retinaculum, 26 wrists were randomised to tourniquet released prior to closure and haemostasis with bipolar diathermy and 24 after closure and dressing application. Immediately after surgery, all patients were asked to indicate the maximum level of pain at the operative and tourniquet sites experienced intra-operatively using a visual analogue score. Patients were assessed for wound healing and symptom relief at 2 and 6 weeks post-operatively. Results were analysed using the Wilcoxon 2-sample test. The use of local anaesthesia and tourniquet was well tolerated in both groups. There was no statistically significant difference between the two groups in pain at the operative or tourniquet site or in wound healing and symptom relief at 2 and 6 weeks post-operatively. Open carpal tunnel decompression under local anaesthesia with tourniquet control is a safe, effective and acceptable technique. The timing of tourniquet release does not affect patient satisfaction, wound healing or symptom relief.     

Selective posterior rhizotomy for lower extremity spasticity: how much and which of the posterior rootlets should be cut?

BACKGROUND: It is well known that selective posterior rhizotomy is effective for relieving spasticity associated with cerebral palsy. However, there is significant variation between surgeons in terms of how much and which of the posterior rootlets should be cut for the improvement of ambulatory function without causing adverse effects. METHODS: The study population was composed of 200 CP patients who underwent SPR more than 1 year before this study. The children were divided into 4 groups (Group A had their L1-S2 roots cut, Group B had the L2-S2 roots cut, Group C had the L2-S1 roots cut, and Group D had the L2-S1 roots and the unilateral S2 root cut). We assessed lower limb spasticity, passive range of motion, ambulatory function, and gait pattern in each group. RESULTS: Inclusion of L1 and S2 in the lesioning process of SPR was more effective at relieving spasticity in terms of hip adduction and ankle dorsiflexion respectively and improving ambulatory function (p < 0.01). Although lesioning of S2 carried a greater risk of urinary dysfunction, resection of less than 50% of S2 significantly improved ambulatory function without urinary complications (p < 0.01). Unilateral lesioning of S2 was an alternative option in selected cases with different amounts of spasticity in the ankles for the same purpose. CONCLUSIONS: We propose that L1 and S2 roots should be included in the lesioning process of SPR for effective improvement of gross motor function, but that resection of these roots should be less than 50% to prevent complications.     

Immunosuppression minimization protocols: how should they be monitored?

This Practice Point commentary discusses the experience of Shapiro et al. with renal allograft recipients at a single center who underwent significant minimization of immunosuppressive treatment with alemtuzumab induction and tacrolimus monotherapy (weaned to three times weekly by 1 year after transplantation). Donor-specific antibodies (DSAs) against human leukocyte antigen were monitored after transplantation in some patients. Although 44% of patients did not develop acute rejection or DSAs and had excellent 2-year graft survival (96%), spaced weaning was not attempted in 20% of patients, generally those with early rejection and poor allograft function. During tapering, 20% of patients developed acute rejection and 15% developed DSAs. Two-year graft survival was 63% in patients for whom weaning was not attempted and 78% in patients who experienced acute rejection. Alemtuzumab preconditioning with tacrolimus monotherapy and spaced weaning increased the risk of acute rejection and development of DSAs. Patients should be carefully selected for this protocol and monitored closely for DSAs. Results of a long-term controlled trial that includes protocol biopsies are required to reach more-definitive conclusions.     

Outcome for the extremely premature neonate: how far do we push the edge?

Significant advances in perinatal and neonatal medicine over the last 20 years and the recent emergence of fetal surgery has resulted in anesthesia providers caring for a growing number of infants born at the margin of viability. Anesthetic management in this patient population has to take into consideration the immature function of many vital organ systems as well as the effects of the underlying disease processes, which can frequently lead to severe physiological derangements. Accordingly, premature infants presenting for major surgeries early in life can represent a significant anesthetic challenge. However, even with advanced anesthetic and surgical management and optimal intensive care, extremely premature infants face substantial postoperative morbidity and mortality, as well as prolonged hospital courses. In this article, we will discuss the following questions: How far have we come in improving outcomes of extreme prematurity? And what will the future medical and societal challenges be, as we continue to redefine the limits of viability?