Laparoscopic pyelolithotomy: Is the retroperitoneal route a better approach?

Objectives:   To compare the outcome of laparoscopic pyelolithotomy (LP) using the transperitoneal and the retroperitoneal routes.
Methods:   Demographics, intraoperative and postoperative clinical parameters were evaluated in 48 laparoscopic pyelolithotomies performed in patients with renal pelvic calculi of diameter >30 mm. The differences between the transperitoneal and retroperitoneal routes were analyzed.
Results:   Twenty-seven LP were performed using the transperitoneal approach (TLP), and 21 using the retroperitoneal approach (RLP). Apart from weight, the patients' demographics and stone size were similar in the two groups. Between the RLP and the TLP routes, the operative time was 112.1 versus 93.2 min ( P  = 0.01), mean time for oral intake was 1.9 versus 1.2 days ( P  < 0.01), and mean hospital stay was 5.2 versus 3.8 days ( P  < 0.01). The mean postoperative analgesic requirement (2.4 vs 2.2 days, P  = 0.41), mean convalescence days (9.7 vs 10 days, P  = 0.56), and mean estimated blood loss (57.2 vs 62.9 ml, P  = 0.5) were similar between RPL and TPL respectively. The stone-free rate at 3 months follow-up was comparable (88.9% vs 90.5%, P  = 0.86). The postoperative complications were not significantly different.
Conclusions:   Compared with the TLP approach, RLP for large renal pelvic stone resulted in a shorter operative time, a shorter resumption time for normal oral intake, and a shorter hospital stay. As the other clinical outcomes are similar, including the stone-free rate, we recommend the RLP route for LP.     

Association of benign prostatic hyperplasia and hernia inguinale. A report of 55 cas

THE AIM: of this study is to evaluate the results of combined surgery of prostatic disease and inguinal hernia repair. METHODS:We report a retrospective study of 55 patients operated in the same operating time for benign prostatic hyperplasia and hernia inguinale, and present our criteria for patient selection, operative technique, and postoperative results. RESULTS:The mean age of our patient was 69 years with a range of 56 to 85 years. Open suprapubic prostatectomy was done in 53% of cases, transurethral prostatic resection in 47% of cases and prothetic hernioplasty in 60% of cases. The incidence of postoperative wound infection and recurrent hernia was 5,4 % and 6% respectively, witch compares favorably to results of herniorraphy and prostatectomy performed separately. Simultaneous repair of inguinal hernias and surgery of prostatic disease is effective and technically feasible.     

Risk-adjusted morbidity, mortality and failure-to-rescue models for internal provider profiling after major lung resection

This work was aimed at developing risk-adjusted outcome models for profiling the internal quality of care after major lung resection. One thousand and sixty-two patients submitted to lobectomy (845) or pneumonectomy (217) from 1994 through 2004 at our unit were analyzed. Risk-adjusted models of 30-day or in-hospital morbidity, mortality and failure-to-rescue (death/complication ratio) were developed by stepwise logistic regression analyses and validated by bootstrap procedures. The regression equations were then used to estimate the outcome risks in 3 successive periods of activity (early: 1994-1997; intermediate: 1998-June/2001; late: July/2001-2004). Observed and predicted morbidity, mortality and failure-to-rescue rates were compared within each period by the z-test. The following regression models were developed: Predicted morbidity: ln R/1-R=-2.1+0.035 x age-0.02 x FVC+0.6 x extended resection+0.7 x cardiac co-morbidity (c-index=0.68). Predicted mortality: ln R/1-R=-7.6+0.08 x age-0.04 x ppoFEV1+1.6 x extended resection+1.2 x cardiac co-morbidity+1.1 x cerebrovascular co-morbidity (c-index=0.83). Predicted failure-to-rescue: ln R/1-R=-6.7+0.06 x age+1.5 x extended resection+1.2 x cerebrovascular co-morbidity (c-index=0.71). No differences were noted between observed and predicted outcome rates within each period, despite apparent unadjusted differences between periods. The use of risk-adjusted outcome models prevented misleading information derived from the unadjusted analysis of performance. We are currently using these models for internal quality-of-care audit purposes.     

Surgical trainees benefit from good consultant working practices: an audit on the effect on training of a new consultant rota

PURPOSE: To retrospectively assess operative supervision for orthopaedic trainees over an 18 week period when trauma and orthopaedic consultants changed their on call working practice from one week on call to a four day/three day block, during a fortnight period. OUTCOME: The rota changes had important implications on workload and consultant availability to supervise juniors during operation with a positive effect upon training such that trauma surgery supervision rates increased significantly (p<0.001) after the introduction of these new working arrangements. Working life for consultants and ultimately patient care were also felt to improve and consultants' working hours were closer to the European working hours directives.     

Relationship between resistin and aPAI‐1 levels with insulin resistance in Saudi children

Background: Association of resistin with insulin resistance (IR) in humans is still controversial and few studies have investigated the association of plasminogen activator inhibitor‐1 (PAI‐1) with IR in children. The purpose of the present study was therefore to evaluate serum levels of resistin and active PAI‐1 (aPAI‐1) in Saudi children and their association with the various obesity‐related complications. Methods: In this cross‐sectional study, 73 boys and 77 girls with varying body mass index (BMI) were recruited. They were assessed for anthropometric measures and fasting serum levels of glucose, insulin, lipid profile, resistin, angiotensin II (ANG II) and aPAI‐1. Results: Resistin was positively correlated with hips (r = 0.33, P < 0.01), waist (r = 0.23, P < 0.05) and BMI (r = 0.33, P < 0.01). The association of resistin with the markers of obesity was also significant in girls but lost significance in boys. aPAI‐1 was positively correlated with total cholesterol (r = 0.24; P < 0.01), triglycerides (r = 0.2, P < 0.05), HOMA‐IR (r = 0.26, P < 0.01) and insulin (r = 0.26, P < 0.01). The significant association of aPAI‐1 with IR was also true in girls but lost significance in boys. Conclusion: Resistin is not correlated with IR and further studies are needed to explore the role of resistin especially in childhood obesity. In contrast, increased levels of PAI‐1 may contribute to the risk of cardiovascular diseases related to obesity and insulin resistance in children. The observed gender‐related differences in the association between resistin, aPAI‐1 with obesity markers and IR could be attributed to sexual dimorphism in body fat distribution.     

Complications of extrapleural pneumonectomy

Extrapleural pneumonectomy (EPP) is a technically demanding operation that includes two body cavities within the operative field. Avoidance of postoperative deaths requires an experienced team that can identify common morbidities. The ability to recognize and intervene correctly in the early phases of postoperative complications can avoid deaths. Although our group has experienced only 20 deaths following 496 EPPs (4% mortality), there were 328 patients (66%) who suffered morbidity. We have drawn upon our single-institution experience to describe the most common source of morbidity following EPP and to offer successful interventions.     

Pamidronate treatment in rheumatology practice: a comprehensive review

Pamidronate, along with other bisphosphonates, has been used for treatment of bone pain secondary to malignant involvement or metastatic disease for years. Some data, however, have also accumulated on the utility of pamidronate in a variety of benign conditions frequently handled by rheumatologists. This study aims to review the available published data regarding the potential use of pamidronate in rheumatology practice. Methods include the review of relevant articles retrieved by a PUBMED search utilizing the index term “pamidronate”. All available randomized control trials, open trials, and case series, as well as properly reported case studies evaluating usage of pamidronate in rheumatic disorders, have been included in the literature review. The efficacy of pamidronate in patients with spondyloarthropathies; synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome; hypertrophic osteoarthropathy; osteoporotic vertebral fractures; chronic back pain due to disk disease or spinal stenosis; Charcot arthropathy; transient osteoporosis; and complex regional pain syndrome-I, has been demonstrated in more than 40 reports, the majority of which, however, were not controlled studies. In some of reviewed conditions, aside from providing analgesic relief, pamidronate may also have disease-modifying properties. While used in different doses in a variety of rheumatic disorders, pamidronate was generally reported to be well tolerated with an overall good safety profile. Pamidronate may represent an effective and safe choice for a spectrum of rheumatic patients, suffering from intractable musculoskeletal pain, unresponsive to traditionally recommended therapies. Large randomized, controlled studies examining the efficacy of pamidronate in the rheumatic conditions are urgently needed.     

Air leaks after lobectomy increase the risk of empyema but not of cardiopulmonary complications: a case-matched analysis

PURPOSE: To assess whether the presence and duration of air leaks after lobectomy are associated with an increased incidence of cardiopulmonary complications. METHODS: Propensity score analysis was used on 726 patients undergoing pulmonary lobectomy from 1995 through 2004 to form three well-matched pairs of patients: patients with prolonged air leak (PAL) [> 7 days] and without air leak; patients with short air leak (SAL) [< or = 7 days] and without air leak; and patients with SAL and PAL. These matched groups were then compared to assess postoperative hospital stay and early outcome. RESULTS: Patients with SAL had a longer postoperative hospital stay compared to patients without air leak (8.6 days vs 7.8 days, respectively; p < 0.0001) but had similar morbidity and mortality. Patients with PAL had a longer postoperative hospital stay compared to patients without air leak (16.2 days vs 8.3 days, respectively; p < 0.0001) and with SAL (16.9 days vs 9 days, respectively; p < 0.0001), but similar cardiopulmonary complications were noted between the groups. Patients with PAL had a higher rate of empyema compared to patients without air leak and with SAL (8.2% vs 0%, p = 0.01 and 10.4% vs.1.1%, p = 0.01, respectively). CONCLUSIONS: The presence of air leak was not associated with an increased incidence of cardiopulmonary morbidity but was associated with an increased risk of empyema. Future prospective studies are needed to confirm safety of fast track in patients with air leak.