A triple-blinded randomized trial comparing the hemostatic effects of large-dose 10% hydroxyethyl starch 264/0.45 versus 5% albumin during major reconstructive surgery

In Canada, hydroxyethyl starch 264/0.45 (HES 264/0.45; molar weight 264 kDa, molar substitution 0.45) has largely replaced albumin as the colloidal fluid of choice for perioperative intravascular volume expansion. The maximum recommended dose of HES 264/0.45 is 28 mL/kg; however, there are no clinical data supporting this limit. In this study we compared the hemostatic effects of HES 264/0.45 versus 5% albumin in doses up to 45 mL/kg over 24 h during major reconstructive head and neck surgery. Fifty patients were randomized to receive HES 264/0.45 or 5% human albumin from the induction of anesthesia until 24 h thereafter. Both albumin and HES 264/0.45 effectively maintained physiologic variables in the perioperative and postoperative periods. The partial thromboplastin time and international normalized ratio were significantly increased in the HES 264/0.45 group compared with the albumin group after infusion of 30 mL/kg and 45 mL/kg (P < 0.05). Factor VIII activity and von Willebrand factor level were significantly reduced in the HES 264/0.45 group compared with the albumin group after infusion of 15 mL/kg, 30 mL/kg, and 45 mL/kg (P < 0.05). Significantly more subjects in the HES 264/0.45 group received allogeneic red blood cell transfusions (P < 0.02). We conclude that HES 264/0.45 infusions >30 mL/kg over 24 h impair coagulation to a greater extent than albumin, possibly leading to more allogeneic transfusions.     

Health Care Expenditures Associated With Skeletal Fractures Among Medicare Beneficiaries, 1999–2005

Fractures impose substantial burdens, in terms of both costs and health, on individuals and health care systems. This is particularly true for older Americans and the Medicare system. The objective of this study was to estimate the costs of care associated with selected fractures among Medicare beneficiaries. This was a retrospective, person‐level, pre/postfracture analysis using administrative data. The study used Medicare claims data from 1999 through 2005 for a 5% sample of Medicare beneficiaries. The subjects included Medicare beneficiaries, ≥65 yr of age, who had at least 13 mo of both Parts A and B coverage and not enrolled in Medicare Advantage and who experienced a closed fracture of the hip, femur, pelvis, tibia/fibula, ankle, distal forearm, nondistal radius/ulna, humerus, clavicle, spine, or wrist, or any fracture of the distal forearm or ankle during the years 2000 through 2005. The main outcome measures were incremental (greater than baseline) and attributable (directly associated) payments for Medicare‐covered services for the first 6 mo after incident fractures. Incremental payments ranged from $7788 (95% CI, $7550–$8025) for distal forearm fractures to $31,310 (95% CI, $31,073–$31,547) for open hip fractures; the attributable payments for distal forearm and hip fractures were $1856 and $18,734, respectively. Fractures are associated with substantial increases in health services utilization and costs among Medicare beneficiaries, but significant proportions of those costs are not directly attributable to fracture treatment. Further research is needed to ascertain other health conditions that are driving costs for Medicare beneficiaries after fractures.     

Evaluation of adhesion formation, mesh fixation strength, and hydroxyproline content after intraabdominal placement of polytetrafluoroethylene mesh secured using titanium spiral tacks, nitinol anchors, and polypropylene suture or polyglactin 910 suture

Background The purpose of this study is to evaluate fixation methods for polytetrafluoroethylene (ePTFE) mesh with an in vivo model of laparoscopic ventral hernia repair.Methods In 40 New Zealand white rabbits, a 4 × 4-cm ePTFE mesh (n = 80, two per animal) was attached to an intact peritoneum with polyglactin 910 (PG 910) (n = 20) or polypropylene (PP) (n = 20) suture, titanium spiral tacks (TS) (n = 20), or nitinol anchors (NA) (n = 20). Mesh was harvested at 8 and 16 weeks for fixation strength testing, adhesion assessment, and collagen (hydroxyproline) content. Fixation strength on day 0 was determined with mesh attached to harvested abdominal wall. Statistical significance was determined as p < 0.05.Results There was no difference in fixation strength between PP (39.1 N) and PG 910 (40.0 N) sutures at time zero. At week 8, PP (25.7 N) was significantly stronger (p < 0.05) than PG 910 (11.4 N) suture, but not at week 16. The fixation strength of TS and NA (day 0, 15.4 vs 7.4 N; week 8, 17.5 vs 15.3 N; week 16, 19.1 vs 13.8 N) was not significantly different. Fixation with PP suture was significantly (p < 0.05) stronger than that with TS and NA at day 0 (39.1, 15.4, and 7.4 N, respectively) but not at weeks 8 or 16. The fixation strength of suture decreased significantly (p < 0.05) from day 0 to week 16 (PP: day 0 = 39.1 N, week 8 = 25.7 N, week 16 = 21.4 N; PG 910: day 0 = 40.0 N, week 8 = 11.4 N, week 16 = 12.8 N). The fixation strength of NA and TS did not change significantly (NA: day 0 = 7.4 N, week 8 = 15.3 N, week 16 = 13.8 N; TS: week 0 = 15.4 N, week 8 = 17.5 N, week 16 = 19.1 N). There were no differences in adhesion area based on fixation device used; however, there were more (p < 0.05) mesh samples using NA with adhesions compared to TS and adhesion tenacity was greater (p < 0.05) compared to that of TS, PP, and PG. Hydroxyproline content at weeks 8 and 16 was similar for all fixation devices.Conclusions The initial fixation strength for nonabsorbable suture is significantly greater than that of the metallic fixation devices, but after 8 weeks there is no difference. Laparoscopic ventral hernia repair without transabdominal suture fixation may be predisposed to acute failure. The metallic devices have similar fixation strength, although the incidence of adhesions and tenacity of adhesions appear to be greater with the nitinol anchors. Since these devices have similar fixation strengths and most likely provide adequate supplementation to transabdominal sutures for mesh fixation after laparoscopic ventral hernia repair, their use should be based on other factors, such as their propensity for adhesions, ease of application, and cost.Paper presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Denver, Colorado, USA, March 31–April 3, 2004     

Previously unreported high-grade complications of adrenalectomy

Background  Serious complications of adrenalectomy are rare but the incidence may be underestimated if they occur outside major referral centers. We report five cases of high-grade complications after adrenalectomy that have not been previously described. Methods  The records of five cases of adrenalectomy performed at outside hospitals were reviewed. Four cases were referred for management of complications and one for medical-legal review. The nature of the adrenal lesion, operative approach, complication(s), and subsequent clinical course and complication management were assessed. Both open adrenalectomy (OA) and laparoscopic adrenalectomy (LA) cases were included. Results  Operative indications were pheochromocytoma (N = 3), aldosteronoma (N = 1), and a nonfunctioning 6-cm hypervascular mass (N = 1). Complications of adrenalectomy included: case 1—complete transection of the porta hepatitis during right LA resulting in hepatic failure requiring emergent liver transplantation; case 2—ligation of the hepatic artery during right OA resulting in recurrent cholangitis and bile duct sclerosis requiring liver transplantation; case 3—ligation of the left ureter during LA resulting in postoperative hydronephrosis and loss of renal function; case 4—loss of left kidney function after OA, likely secondary to renal artery ligation ultimately requiring laparoscopic nephrectomy; case 5—LA of a normal adrenal gland for a 6-cm hypervascular mass thought to be arising from the adrenal gland. Three-month postoperative imaging demonstrated a persistent mass and the patient underwent hand-assisted laparoscopic nephrectomy for a left upper pole renal cell carcinoma that was missed at the time of LA. Conclusion  Despite the generally low morbidity of adrenalectomy, serious and potentially life-threatening complications can occur. Surgeon inexperience may be a factor in the occurrence of some of these complications which have not been previously described.     

Passive Pneumatic Stabilization Device for Assisting in Reduction of Femoral Shaft Fractures

Abstract During treatment of femoral shaft fractures, not only the actual fracture reduction but also the retention of the achieved reduction is essential. Substantial forces may apply to the bone fragments, due to multidirectional muscular contraction. Furthermore, forces from manipulation of one bone fragment may be transferred over the soft tissues onto the other fragments, thus hindering accurate fracture reduction. Once a sufficient reduction has been achieved, this position must be retained whilst definitive internal fixation is performed. Conventional methods comprise mounting patients on a traction table and applying manual distraction or employing special distraction devices, such as the AO distractor device. These approaches, however, only insufficiently stabilize both main fragments. For example, on the traction table the proximal femoral fragment can pivot around the hip joint thus complicating precise reduction. A novel pneumatic stabilization device to assist surgeons during operative procedures is described. This passive holding device “Passhold” connects to one main fragment through a minimally invasive bone interface and statically locks the fragment’s position. Thereafter, only the other main fragment is manipulated to achieve reduction. Mutual interference of the reciprocal fragment positions, due to soft-tissue force transfer during manipulation, is avoided. The authors examined the stability of the novel retention device on a test rig and proved its functionality under sterile settings using cadaver tests. It is concluded that this device largely facilitates the operative procedure in femoral shaft fractures, is sufficiently stable and ergonomically suitable for intraoperative deployment.     

Current status of temporomandibular joint arthroscopy in the United Kingdom

In an era during which minimally invasive procedures are increasingly becoming the norm, arthroscopy of the temporomandibular joint (TMJ) seems to be infrequently used for diagnosis and treatment of disorders of the TMJ. The reasons for this are not clear. The purpose of this study was to find out the current state of arthroscopy of the TMJ in the UK and, more specifically, how often it is used, the indications for its use, the level of experience of practising surgeons, and the reasons for not using it. Information was gathered between 2009 and 2010 from a postal and e-mail questionnaire to all oral and maxillofacial consultants in the UK. Of the 346 consultants, 215 (60%) responded to the questionnaire. Forty-two said that they currently used arthroscopy of the TMJ, and 33 of those (81%) have more than 5 years' experience. During the past year, a total of 8 consultants nationally have done 20 arthroscopies or more. Thirty-three of the procedures (81%) were done for both diagnosis and treatment. Lack of perceived need of patients and lack of interest in this specialty were the main reasons given for not doing arthroscopy, lack of training being a key secondary reason. The Storz and Olympus systems were the most commonly used within the UK. Results seem to support the opinion that arthroscopy of the TMJ is under-used, and consideration should be given to ensuring that trainees are instructed in its use, which is important in the diagnosis and treatment of disorders of the TMJ.     

Intermediate-range sweat chloride concentration and Pseudomonas bronchitis. A cystic fibrosis variant with preservation of exocrine pancreatic function

We studied the clinical and laboratory characteristics of seven patients with sweat chloride concentration consistently between 40 and 60 mEq/liter. Each has chronic Pseudomonas bronchitis, and all lack digestive symptoms. Laboratory findings indicate the preservation of exocrine pancreatic function. The patients include two of five children in one family and two of four in another. In a third family, one of five siblings has an intermediate sweat chloride concentration, but another has a typical fibrosis value (105 mEq/liter). One patient died of respiratory failure; results of an autopsy showed bronchiolectasis typical of cystic fibrosis, but minimal pancreatic changes. The data suggest a genetic basis for this variant of cystic fibrosis. These patients may be homozygous for a portion of a closely linked multigene cystic fibrosis locus or may have modifier genes that ameliorate the pancreatic and sweat lesions.     

Photodynamic therapy: response of normal canine urethra using a cylindrical fiber

Normal urethral response to photodynamic therapy (PDT) utilizing a cylindrical fiber was assessed in ten study and two control NIH fox-hounds. The canine urethras were treated 48 hours after intravenous injection of 3 mg/kg dihematoporphyrin ether (Photofrin II). A 1-mm fused silica optical fiber, with the distal 2-3 cm modified for cylindrical light distribution (660-microns diameter), was placed in the pendulous urethra. An argon-pumped dye laser delivered 100 mW of 630-nm light for 7 minutes (42 J) to the treatment area. Urethroscopy using either a 2.5-mm or a 2.8-mm flexible pediatric bronchoscope with video recording capability was performed immediately after PDT (12 animals) and 6 weeks later (nine animals); intravenous urography was performed 3 days and 6 weeks after PDT. There was no evidence of either urethral damage or stricture formation in any animal. Histopathology of the first three study specimens, obtained at 6 weeks, confirmed the absence of any pathology. Flexible instrumentation facilitates post-treatment assessment. This study demonstrates for the first time that, when a cylindrical fiber is used, photodynamic therapy may be applied to the urethra without damage to the normal urethral mucosa. This result has implications for potential treatment of initial or recurrent carcinoma in situ of the urethra using PDT.