Preoperative Education in Cholecystectomy in the Context of a Multimodal Protocol of Perioperative Care: A Randomized, Controlled Trial

Background

Preoperative education is a key point in multimodal protocols of perioperative care. We investigated whether preoperative education for patients undergoing open cholecystectomy would reduce the incidence of perioperative symptoms.

Methods

This was a randomized, single-blinded, clinical trial that included adult (18–65 years old) candidates for elective open cholecystectomy. All patients took part in the ERAS/ACERTO protocol of perioperative care except that only the intervention group received preoperative education. The main endpoints of the study were the presence and intensity of postoperative symptoms (e.g., nausea, vomiting, pain) measured by a visual analogue scale, 24 h after the operation.

Results

A total of 74 patients (34 in the intervention group, 40 in the control group) completed the study. The intervention group had significantly lower median (interquartile range) scores for nausea [0 (4) vs. 2.5 (5.8), p = 0.04] and pain [0.2 (2.3) vs. 3.1 (3.45), p < 0.01] than the controls. High well-being (score ≥6) was reported by 79.4 % (27 patients) of the intervention group in contrast to 57.5 % (23 patients) of the controls (p = 0.04).

Conclusions

Preoperative education is highly effective in the context of a multimodal protocol for enhancing the recovery of patients submitted to open cholecystectomy.     

Trabecular Bone Score and Hip Structural Analysis in Patients With Atypical Femur Fractures

Bisphosphonate use has declined dramatically in recent years, partly because of fear of rare side effects like atypical femur fractures (AFFs). It is therefore desirable to have a diagnostic method to identify those at risk of AFF to prevent this serious complication. We compared trabecular microarchitecture and hip geometry between 30 patients with AFF and 141 controls of similar age and sex, using bisphosphonates. Trabecular bone score (TBS) and hip structural analysis (HSA) were used to assess trabecular microarchitecture and macroscopic hip geometry from dual-energy X-ray absorptiometry images of the lumbar spine and hip, respectively. General characteristics, TBS, and HSA were compared between patients with AFF and controls using Student's t tests and chi-square statistics. Associations between AFF and TBS and femur geometric characteristics by HSA were adjusted for sex, age, height, weight, ethnicity, duration of bisphosphonate use, and glucocorticoid use. Additionally, the analysis of TBS was adjusted for lumbar spine bone mineral density and the time difference between dual-energy X-ray absorptiometry scanning and the diagnosis of AFF. Patients with AFF had significantly higher body mass index than controls, had used bisphosphonates longer, and glucocorticoids and proton pump inhibitors more frequently. Sex-specific T-score was significantly higher in patients with AFF at the lumbar spine (p?=?0.004), but not at the femoral neck (p?=?0.190) after adjustment for age, height, and weight. TBS did not differ significantly between patients with AFF and controls. Neither neck shaft angle nor any geometric variables at the femoral shaft measured by HSA differed between patients with AFF and controls. At the narrow neck, patients with AFF had lower buckling ratio and higher centroid position, consistent with a lower risk of classical fragility hip fractures. The findings at narrow neck and higher bone mineral density might be explained by the fact that the majority of patients with AFF used bisphosphonates to prevent glucocorticoid-induced osteoporosis. Based on our results, TBS and HSA do not appear to have value in detecting patients at risk of AFF.     

Acute penetrating atherosclerotic ulcer of the ascending aorta

A 67‐year‐old man presented with chest pain. Clinical examination revealed hypertension (160/90 mm Hg). Electrocardiogram indicated no acute coronary syndrome and cardiac enzymes were normal. Catheterization was performed owing to the patient’s continuing chest pain and ascending aortogram revealed irregular aortic wall. A computed tomography image showed the shape of penetrating ulcer. The patient was taken to the operating room and intraoperative examination confirmed the diagnosis of penetrating atherosclerotic ulcer (PAU). Coronary artery bypass graft and bovine pericardial patch repair of PAU was performed. A bovine pericardial patch was done as aortic root was heavily calcified and was easy to handle and more hemostatic.     

Mindfulness‐based program for stress reduction in infertile women: Randomized controlled trial

Infertile women often experience chronic stress, which may have a negative impact on general well‐being and may increase the burden of infertility. In this open‐label, parallel, randomized controlled trial, infertile women aged 18–50 years (median 37 years) were assigned to an 8‐week mindfulness‐based program (MBP) or no intervention. The primary outcome was stress severity measured by the Lipp's Stress Symptoms Inventory (ISSL). Data were analyzed by modified intent‐to‐treat principle, which included all cases available to follow‐up regardless of adherence to the intervention (62 participants from the MBP group and 37 from the control group). The median number of symptoms of chronic stress recorded in the past month decreased from six (interquartile range 2 to 9) before the MBP to two (interquartile range 1 to 4) after the intervention (p < 0.001, repeated measures analysis of variance with Time × Group interaction). Depressive symptoms also decreased after MBP, whereas general well‐being improved (p < 0.01 for both outcomes). Hair cortisol and serum brain‐derived neurotrophic factor (BDNF) did not change significantly between preintervention and postintervention. None of the outcomes changed significantly in the control group. MBP was effective in reducing stress and depressive symptoms while increasing general well‐being in infertile women.     

Outcomes following Microvascular Free Tissue Transfer in Reconstructing Skull Base Defects

Objective Successful resection of complex tumors involving the skull base (SB) depends on the ability to reconstruct the resulting defects. The objective of this study was to assess the outcomes of patients undergoing reconstruction after resection of SB tumors with free flaps.Methods From 1995 to 2010 a retrospective review of cases was undertaken. Demographics, histology, surgical management, complications, locoregional control, and survival were analyzed.Results We performed 62 flaps in 57 patients. There was a preponderance of sinonasal malignancies (45%), and most lesions involved the anterior SB (81%). A total of 94% of patients underwent radiotherapy. Reconstruction was undertaken mainly with anterolateral thigh (37%) or radial forearm (34%) flaps. Complications occurred in 17% of patients, and the flap''s success rate was 94%.Conclusion Free flaps are versatile and highly reliable for reconstructing defects resulting from resections of the SB. They should be considered for SB reconstruction of large three-dimensional defects as well as defects involving an irradiated field. Successful reconstruction of the SB can be performed using a small number of highly dependable flaps.     

Changes in nerve growth factor level and symptom severity following antibiotic treatment for refractory overactive bladder

Introduction and hypothesis

Overactive bladder (OAB) has a multifactorial aetiology, and for some women symptoms may be associated with chronic urothelial inflammation secondary to bacterial colonisation. One marker of such inflammation may be urinary nerve growth factor (NGF). We hypothesised that for women with OAB and urothelial inflammation, urinary NGF would be reduced following antibiotic therapy.

Methods

Women with overactive bladder and urodynamic diagnosis of detrusor overactivity who were refractory to anticholinergics, and had histological evidence of urothelial inflammation were treated with a 6-week course of rotating antibiotics. Urinary NGF was measured by ELISA before and after treatment. Three-day bladder diaries, the Patients’ Perception of Intensity of Urgency Scale, the King’s Health Questionnaire and the Patients’ Perception of Bladder Condition questionnaire were used to assess subjective and objective outcomes of therapy.

Results

Thirty-nine women with refractory DO were recruited. The NGF levels decreased significantly after antibiotic therapy (Wilcoxon signed rank test; p?=?0.015). There were significant improvements in daytime frequency, nocturia and urgency (p?<?0.05), and 74 % of women reported improvement in perception of their bladder condition.

Conclusions

Urinary NGF is responsive to antibiotic therapy. Women with refractory overactive bladder and elevated NGF may benefit from antibiotic treatment.     

Alveolar recruitment improves ventilatory efficiency of the lungs during anesthesia

PURPOSE: The goal of this study was to analyze the effect of positive end-expiratory pressure (PEEP), with and without a lung recruitment maneuver, on dead space. METHODS: 16 anesthetized patients were sequentially studied in three steps: 1) without PEEP (ZEEP), 2) with 5 cm H(2)O of PEEP and 3) with 5 cm H(2)O of PEEP after an alveolar recruitment strategy (ARS). Ventilation was maintained constant. The single breath test of CO(2) (SBT-CO(2)), arterial oxygenation, end-expiratory lung volume (EELV) and respiratory compliance were recorded every 30 min. RESULTS: Physiological dead space to tidal volume decreased after ARS (0.45 +/- 0.01) compared with ZEEP (0.50 +/- 0.07, P < 0.05) and PEEP (0.51 +/- 0.06, P < 0.05). The elimination of CO(2) per breath increased during PEEP (25 +/- 3.3 mL.min(-1)) and ARS (27 +/- 3.2 mL.min(-1)) compared to ZEEP (23 +/- 2.6 mL.min(-1), P < 0.05), although ARS showed larger values than PEEP (P < 0.05). Pa-etCO(2) difference was lower after recruitment (0.9 +/- 0.5 kPa, P < 0.05) compared to ZEEP (1.1 +/- 0.5 kPa) and PEEP (1.2 +/- 0.5 kPa). Slope II increased after ARS (63 +/- 11%/L, P < 0.05) compared with ZEEP (46 +/- 7.7%/L) and PEEP (56 +/- 10%/L). Slope III decreased significantly after recruitment (0.13 +/- 0.07 1/L) compared with ZEEP (0.21 +/- 0.11 1/L) and PEEP (0.18 +/- 0.10 1/L). The angle between slope II and III decreased only after ARS. After lung recruitment, PaO(2), EELV, and compliance increased significantly compared with ZEEP and PEEP. CONCLUSION: Lung recruitment improved the efficiency of ventilation in anesthetized patients.     

Safety of cystic duct clipping in healthy and cirrhotic livers: a cadaveric study.

BACKGROUND AND OBJECTIVES: Biliary leakage through the cystic duct stump due to clip dislodgement has been a concern since the advent of the laparoscopic cholecystectomy. The authors proposed a cadaveric model to test the safety of cystic duct clipping in a hypertensive biliary tract in healthy and cirrhotic livers. METHODS: Twenty fresh cadavers were studied (5 cirrhotic, 15 healthy). Open cholecystectomy was performed and the cystic duct clipped with commercially available titanium clips. The distal common bile duct was catheterized to allow infusion of water and pressure measurement. RESULTS: Increased pressure in the bile duct resulted in back diffusion into the liver, preventing reaching high-pressure levels. Only 1 clip was dislodged in this situation, in a cirrhotic liver with a large cystic duct. As a second experiment, the hepatic hilum was clamped to allow higher pressures of the biliary tree (500 mm Hg). In this situation, no clip was dislodged. CONCLUSIONS: We have established the safety of cystic duct clipping in healthy and cirrhotic livers; however, bigger clips or alternative methods to seal the duct may be necessary in larger ducts.     

Distraction osteogenesis for the cleft lip and palate patient

Gradual maxillary distraction by modified osteotomies and external force systems is a procedure with minimal morbidity and few complications. The interaction between surgeons and orthodontists is critical, however. The wide range of possibilities for remodeling a hypoplastic maxilla by distraction allows the potential to simultaneously advance and to elongate the midface, thereby restructuring the skeletal framework with mature new bone. An expansion of all the soft tissues of the face and palate (muscles, nerves, vessels, mucosa, skin) occurs in conjunction with bone elongation. This process ultimately produces excellent functional and aesthetic results in patients with midface deficiency, thus restoring their facial appearance and avoiding many years of facial deformity and associated psychologic sequelae.     

Human plasma as a dermal scaffold for the generation of a completely autologous bioengineered skin

BACKGROUND: Keratinocyte cultures have been used for the treatment of severe burn patients. Here, we describe a new cultured bioengineered skin based on (1) keratinocytes and fibroblasts obtained from a single skin biopsy and (2) a dermal matrix based on human plasma. A high expansion capacity achieved by keratinocytes grown on this plasma-based matrix is reported. In addition, the results of successful preclinical and clinical tests are presented. METHODS: Keratinocytes and fibroblasts were obtained by a double enzymatic digestion (trypsin and collagenase, respectively). In this setting, human fibroblasts are embedded in a clotted plasma-based matrix that serves as a three-dimensional scaffold. Human keratinocytes are seeded on the plasma-based scaffold to form the epidermal component of the skin construct. Regeneration performance of the plasma-based bioengineered skin was tested on immunodeficient mice as a preclinical approach. Finally, this skin equivalent was grafted on two severely burned patients. RESULTS: Keratinocytes seeded on the plasma-based scaffold grew to confluence, allowing a 1,000-fold cultured-area expansion after 24 to 26 days of culture. Experimental transplantation of human keratinocytes expanded on the engineered plasma scaffold yielded optimum epidermal architecture and phenotype, including the expression of structural intracellular proteins and basement-membrane components. In addition, we report here the successful engraftment and stable skin regeneration in two severely burned patients at 1 and 2 years follow-up. CONCLUSIONS: Our data demonstrate that this new dermal equivalent allows for (1) generation of large bioengineered skin surfaces, (2) restoration of both the epidermal and dermal skin compartments, and (3) functional epidermal stem-cell preservation.