Robot-assisted laparoscopic rectovaginopexy for rectal prolapse: a prospective cohort study on feasibility and safety

Robotic systems may be particularly supportive for procedures requiring careful pelvic dissection and suturing in the Douglas pouch, as in surgery for rectal prolapse. Studies reporting robot-assisted laparoscopic rectovaginopexy for rectal prolapse, however, are scarce. This prospective cohort study evaluated the outcome of this technique up to one year after surgery. From January 2005 to June 2006, 15 consecutive patients with a rectal prolapse, either with or without a concomitant rectocele or enterocele, underwent robot-assisted laparoscopic rectovaginopexy with support of the da Vinci robotic system. A prospective cohort study was performed on operating times, blood loss, intra-operative and post-operative complications, and outcome at a minimum of one year after surgery. Median age at time of operation was 62 years (33–72) and median body mass index 24.9 (20.9–33.9). Median robot set-up time was 10 min (3–15) and median skin-to-skin operating time was 160 min (120–180). No conversions to open surgery were necessary. No in-hospital complications occurred and there was no mortality. Median hospital stay was four days (2–9). During one year follow-up, two patients needed surgical reintervention. One patient was operated for recurrent enterocele and rectocele one week after surgery. In another patient an incisional hernia at the camera port occurred three months after surgery. At one year after surgery, 87% of patients claimed to be satisfied with their postoperative result. Robot-assisted laparoscopic rectovaginopexy proved to be an effective technique with favourable outcomes in most patients in this prospective series. The operating team experienced the support of the robotic system as beneficial, especially during the dissection of the rectovaginal plane and suturing in the Douglas pouch.     

Living-related liver transplantation and vena cava reconstruction after total hepatectomy including the vena cava for hepatoblastoma.

BACKGROUND: In most cases of total hepatectomy (TH) required for hepatoblastoma (HB), the retrohepatic inferior vena cava (IVC) has to be removed with the native liver for complete tumor excision. Because the liver graft procured by living donation has no IVC, a reconstruction of the recipient IVC is needed. We report our experience with living-related liver transplantation (LRLT) and IVC replacement in such cases. METHODS: Between May 1998 and December 1999, four children underwent TH, including IVC and LRLT with IVC replacement for otherwise irresectable HB after chemotherapy (SIOPEL 2 and 3 protocols). IVC reconstruction used an allogenic iliac vein procured from a cadaveric donor (bank graft) in two cases and an internal jugular vein procured from the donor parent in two cases. Median age and weight at surgery were 17 months (range 10-60) and 9.6 kg (range 8.3-17.9). RESULTS: In the living donors, there were two complications of the procurement: one intra-abdominal biliary collection and one subcutaneous abscess. In all four children, complete excision of the tumor could be achieved without any intra-operative complication. One patient died 5 months after LRLT due to lung metastases. Three patients were alive and well with no evidence of tumor recurrence 13-24 months after surgery. Reconstructed IVC was patent in two patients, and asymptomatic thrombosis occurred 2 years after operation in one patient. CONCLUSION: Total hepatectomy including the retrohepatic IVC is not a technical obstacle to LRLT. Therefore, scheduled surgery, at the best time after chemotherapy, can be considered in all patients with otherwise irresectable HBs.     

Comparison of Two Different Temperature Maintenance Strategies during Open Abdominal Surgery: Upper Body Forced-air Warming versus Whole Body Water Garment

Background: A new system has been developed that circulates warm water through a whole body garment worn by the patient during surgery. In this study the authors compared two different strategies for the maintenance of intraoperative normothermia. One strategy used a new water garment warming system that permitted active warming of both the upper and lower extremities and the back. The other strategy used a single (upper body) forced-air warming system.

Methods: In this prospective, randomized study, 53 adult patients were enrolled in one of two intraoperative temperature management groups during open abdominal surgery with general anesthesia. The water-garment group (n = 25) received warming with a body temperature (rectal) set point of 36.8[degrees]C. The forced-air-warmer group (n = 28) received routine warming therapy using upper body forced-air warming system (set on high). The ambient temperature in the operating room was maintained constant at approximately 20[degrees]C. Rectal, distal esophageal, tympanic, forearm, and fingertip temperatures were recorded perioperatively and during 2 h after surgery. Extubated patients in both groups were assessed postoperatively for shivering, use of additional warming devices, and subjective thermal comfort.

Results: The mean rectal and esophageal temperatures at incision, 1 h after incision, at skin closure, and immediately postoperatively were significantly higher (0.4-0.6[degrees]C) in the group that received water-garment warming when compared with the group that received upper body forced-air warming. The calculated 95% confidence intervals for the above differences in core temperatures were 0.7-0.1, 0.8-0.2, 0.8-0.2, and 0.9-0.1, retrospectively. In addition, 14 and 7% of patients in the control upper body forced-air group remained hypothermic (< 35.5[degrees]C) 1 and 2 h after surgery, respectively. No core temperature less than 35.5[degrees]C was observed perioperatively in any of the patients from the water-garment group. A similar frequency of the thermal stress events (shivering, use of additional warming devices, subjective thermal discomfort) was observed after extubation in both groups during the 2 h after surgery.     

Low-intensity pulsed ultrasound in the treatment of nonunions

BACKGROUND: Low-intensity ultrasound has demonstrated an acceleration of bone healing and more profound callus formation in animal and human clinical experiments. In this study, the effect of pulsed, low-intensity ultrasound was determined in established nonunion cases. METHODS: The enrolled cases were reviewed for the time from their last surgical procedure and evidence of no healing or progression of healing during the 3 or more months before the start of low-intensity ultrasound therapy to determine whether the cases were established nonunions. Twenty-nine cases, located in the tibia, femur, radius/ulna, scaphoid, humerus, metatarsal, and clavicle, met the criteria for established nonunions. On average, the postfracture period before the start of ultrasound treatment was 61 weeks. Initial fracture treatment was conservative in 8 cases and operative in 21 cases. Additional treatments including bone grafting, reosteosynthesis, and other surgical procedures were performed an average of 52 weeks before the start of ultrasound treatment. Daily, 20-minute applications of low-intensity ultrasound at the site of the nonunion were performed by the patients at home. RESULTS: Twenty-five of the 29 nonunion cases (86%) healed in an average treatment time of 22 weeks (median, 17 weeks). Stratification of the healed and failed outcome for age, gender, concomitant disease, bone location, fracture age, prior last surgery interval, nonunion type, smoking habits, and fixation before and during treatment showed a significant difference only in the smoking habit strata. CONCLUSION: Noninvasive ultrasound therapy can be useful in the treatment of challenging, established nonunions.     

Diet and asthma in Dutch school children (ISAAC-2)

BACKGROUND: The rise in the prevalence of asthma in western societies may be related to changed dietary habits. Epidemiological studies in children have shown inverse associations of asthma related outcomes with intake of fruits, vegetables, dairy and whole grain products, and fish. In contrast to most previous studies, we used both questionnaire and clinical data to define asthma. METHODS: Intake of the abovementioned foods was studied in relation to asthma in 598 Dutch children aged 8-13 years. Dietary intake was estimated using a parent completed semi-quantitative food frequency questionnaire. Current wheeze and current asthma were defined based on questionnaire data. More complex end points were defined using information on bronchial hyperresponsiveness (BHR) and atopic sensitisation as well. Linear associations were studied using logistic regression analysis and odds ratios presented for the highest versus the lowest tertile of intake. In the final models, adjustments were made for maternal educational level, foreign descent, and total energy intake. RESULTS: The intake of whole grain products and of fish was inversely associated with asthma. Adjusted odds ratios for the independent associations with whole grains and fish were 0.46 (95% CI 0.19 to 1.10) and 0.34 (95% CI 0.13 to 0.85) for current asthma and 0.28 (95% CI 0.08 to 0.99) and 0.12 (95% CI 0.02 to 0.66) for atopic asthma with BHR. Similar results were observed for current wheeze and atopic wheeze with BHR. Intake of (citrus) fruits, vegetables, and dairy products showed no clear associations with asthma end points. CONCLUSIONS: Our findings suggest that a high intake of whole grain products and fish may have a protective effect against asthma in children.     

Sex differences in the use of absorbent (incontinence) pads in independently living elderly people: do men receive less care?

Aim: To examine the use and satisfaction of absorbent (incontinence) pads in independently living men and women aged 60 and above with urinary incontinence (UI). Methods: The subjects participated in a large‐scale study about the prevalence of UI. All the independently living patients in nine family practices aged 60 or above with uncomplicated UI, who were willing to participate in the study were interviewed at home. Results: In total, 56 men and 314 women were interviewed. Fifteen per cent of the men and 87% of the women with UI used pads. All men and nine out of 10 women used different kinds of absorbent pads, and half of the men and women used pads specifically made for UI. Only half of the men and two‐third of the women felt satisfied with the pads. The reasons for not being satisfied were: leakage, irritation and discomfort. The use of pads, the use at daytime and the type of pads were correlated to the severity of incontinence. Conclusion: Only one out of nine men with UI uses pads in contrast with four out of five women. Only half of them wear pads specifically made for UI. Men are less satisfied about the pads compared with women.     

Polyarteritis nodosa associated with hepatitis B virus infection. The role of antiviral treatment and mutations in the hepatitis B virus genome

Polyarteritis nodosa (PAN) is a systemic inflammatory disease causing vasculitis of medium sized and small arteries. Circulating immune complexes containing viral proteins have been implicated in the pathogenesis of hepatitis B virus (HBV) related PAN and several immunosuppressive and antiviral regimens have been used with varying success. In our hospital seven HBV positive patients with a confirmed diagnosis of PAN could be identified between 1984 and 2001. Most patients had an acute HBV infection and all patients were treated with prednisone. A combination of prednisone and antiviral therapy with alpha-interferon (IFN) was used only in the last four patients. HBV DNA was isolated from serum samples obtained before treatment from the four IFN treated patients and amplified by using the polymerase chain reaction technique. None of the patients without, but two of four with antiviral therapy exhibited HBsAg seroconversion. In three out of four patients HBV DNA decreased rapidly after starting IFN therapy. Clinical remission of PAN was observed in three of the four treated patients, but in none of the three patients who were not receiving antiviral medication. Analysis of the HBV genome revealed no mutations that could be associated with PAN. In one patient a stop codon in the pre-core region and a double mutation A1762T-G1764A were found during antiviral therapy. We did not find HBV heterogeneity predisposing to the development of PAN. In our group of patients it appeared that clinical remission of PAN was primarily related to spontaneous or therapy induced loss of HBV DNA replication. The combined administration of a priming steroid course and IFN appears to be an improvement over prednisone monotherapy and should be considered for every patient with HBV related PAN. The efficacy of new generation nucleoside analogues should be further elucidated in future studies.     

Protease inhibitors and cardiovascular outcomes in patients with HIV-1

Protease inhibitors for treatment of HIV-1 have been linked with increased risk of hyperlipidaemia and hyperglycaemia. In a cohort of 5672 outpatients with HIV-1 seen at nine US HIV clinics between January, 1993, and January, 2002, the frequency of myocardial infarctions increased after the introduction of protease inhibitors in 1996 (test for trend, p=0.0125). We noted that 19 of 3247 patients taking, but only two of 2425 who did not take, protease inhibitors had a myocardial infarction (odds ratio 7.1, 95% CI 1.6-44.3; Cox proportional hazards model-adjusted for smoking, sex, age, diabetes, hyperlipidaemia, and hypertension-hazard ratio 6.5, 0.9-47.8). Our findings suggest that, although infrequent, use of protease inhibitors is associated with increased risk of myocardial infarction in patients with HIV-1.