Laparoscopic repair of hiatus hernia: Does mesh type influence outcome? A meta-analysis and European survey study

Background

Synthetic mesh (SM) has been used in the laparoscopic repair of hiatus hernia but remains controversial due to reports of complications, most notably esophageal erosion. Biological mesh (BM) has been proposed as an alternative to mitigate this risk. The aim of this study is to establish the incidence of complications, recurrence and revision surgery in patients following suture (SR), SM or BM repair and undertake a survey of surgeons to establish a perspective of current practice.

Methods

An electronic search of EMBASE, MEDLINE and Cochrane database was performed. Pooled odds ratios (PORs) were calculated for discrete variables. To survey current practice an online questionnaire was sent to emails registered to the European Association for Endoscopic Surgery.

Results

Nine studies were included, comprising 676 patients (310 with SR, 214 with SM and 152 with BM). There was no significant difference in the incidence of complications with mesh compared to SR (P = 0.993). Mesh significantly reduced overall recurrence rates compared to SR [14.5 vs. 24.5 %; POR = 0.36 (95 % CI 0.17–0.77); P = 0.009]. Overall recurrence rates were reduced in the SM compared to BM groups (12.6 vs. 17.1 %), and similarly compared to the SR group, the POR for recurrence was lower in the SM group than the BM group [0.30 (95 % CI 0.12–0.73); P = 0.008 vs. 0.69 (95 % CI 0.26–1.83); P = 0.457]. Regarding surgical technique 503 survey responses were included. Mesh reinforcement of the crura was undertaken by 67 % of surgeons in all or selected cases with 67 % of these preferring synthetic mesh to absorbable mesh. One-fifth of the respondents had encountered mesh erosion in their career.

Conclusions

Both SM and BM reduce rates of recurrence compared to SR, with SM proving most effective. Surgical practice is varied, and there remains insufficient evidence regarding the optimum technique for the repair of hiatal hernia.

     

Differences between the pediatric and adult presentation of fibromuscular dysplasia: results from the US Registry

Background

Fibromuscular dysplasia (FMD) is a non-inflammatory arteriopathy that causes significant morbidity in children.

Methods

The clinical features, presenting symptoms, and vascular beds involved are reviewed in the first 33 patients aged <18 years who are enrolled in the United States Registry for FMD from five registry sites and compared with 999 adult patients from 12 registry sites.

Results

Mean age at diagnosis was 8.4?±?4.8 years (16 days to 17 years). Compared with adults, pediatric FMD occurs in more males (42.4 vs 6 %, p?<?0.001). Children with FMD have a stronger previous history of hypertension (93.9 vs 69.9 %, p?=?0.002). Hypertension (100 %), headache (55 %), and abdominal bruits (10.7 %) were the most common presenting signs and symptoms. FMD affects renal vasculature in almost all children (97 vs 69.7 %, p?=?0.003). The extra-cranial carotid vessels are less commonly involved in children (23.1 vs 73.3 %, p?<?0.001). The mesenteric arteries (38.9 vs 16.2 %, p?=?0.02) and aorta (26.3 vs 2.4 %, p?<?0.001) are more commonly involved in children.

Conclusions

In the United States Registry for FMD, pediatric FMD affects children from infancy throughout childhood. All children presented with hypertension and many presented with headache and abdominal bruits. In children, FMD most commonly affects the renal vasculature, but also frequently involves the mesenteric arteries and abdominal aorta; the carotid vessels are less frequently involved.

     

Febrile urinary tract infection after pediatric kidney transplantation: a multicenter,prospective observational study

Background

Febrile urinary tract infections (fUTIs) are common after kidney transplantation (KTx); however, prospective data in a multicenter pediatric cohort are lacking. We designed a prospective registry to record data on fUTI before and after pediatric KTx.

Methods

Ninety-eight children (58 boys and 40 girls)?≤?18 years from 14 mid-European centers received a kidney transplant and completed a 2-year follow-up.

Results

Posttransplant, 38.7 % of patients had at least one fUTI compared with 21.4 % before KTx (p?=?0.002). Before KTx, fUTI was more frequent in patients with congenital anomalies of kidneys and urinary tract (CAKUT) vs. patients without (38 % vs. 12 %; p?=?0.005). After KTx, fUTI were equally frequent in both groups (48.7 % vs. 32.2 %; p?=?0.14). First fUTI posttransplant occurred earlier in boys compared with girls: median range 4 vs. 13.5 years (p?=?0.002). Graft function worsened (p?<?0.001) during fUTI, but no difference was recorded after 2 years. At least one recurrence of fUTI was encountered in 58 %.

Conclusion

This prospective study confirms a high incidence of fUTI after pediatric KTx, which is not restricted to patients with CAKUT; fUTIs have a negative impact on graft function during the infectious episode but not on 2-year graft outcome.

     

Longitudinal assessment of renal size and function in extremely low birth weight children at 7 and 11 years of age

Background

There are a lack of studies describing a longitudinal association between preterm delivery and renal complications later in life. We assessed renal size and function in preterm infants born with extremely low birth weight (ELBW) during 4 years of follow-up, comparing these parameters to age-matched children born full term (term controls).

Methods

The results of selected renal laboratory tests [levels of cystatin C, creatinine, blood urea nitrogen (BUN)] and of renal ultrasound evaluations were compared between the ELBW group and the term control group at age 7 and 11 years.

Results

The study population consisted of 64 children born with ELBW (ELBW children) who had been recruited at birth and 36 children born at term (term children) who took part in both follow-up assessments. Renal ultrasound examination revealed a significantly smaller renal volume in the 7- and 11-year-old ELBW children compared to the term controls [right kidney volume: 50.8 vs. 61.2 ml/m², respectively, at 7 years (p <0.01) and 51.4 vs. 58.2 ml/m², respectively, at 11 years (p <0.01); left kidney volume: 51.4 vs. 60.3 ml/m², respectively, at 7 years (p <0.01) and 55.2 vs. 60.7 ml/m², respectively, at 11 years (p?=?0.02)]. Renal function in ELBW children was also affected. Serum cystatin C levels were significantly higher in ELBW children than in the controls at 7 years of age, and this difference remained statistically significant at 11 years of age [0.63 vs. 0.59 mg/l, respectively, at 7 years (p?=?0.02) and 0.72 vs. 0.61 mg/l, respectively, at 11 years (p?=?0.01)]. Six ELBW children also had elevated cystatin C levels (0.97–1.11 mg/l) at 11 years of age. Cystatin C levels were within normal range in the ELBW children at age 7 years and in term children in both follow-up studies. BUN levels were higher in ELBW children at the age of 11 years (4.49 vs. 4.15 mmol/l; p?=?0.028).

Conclusion

Continued follow-up of these patients will reveal whether the observed worsening in renal function will persist into adulthood.

     

Effect of curcumin (<Emphasis Type="Italic">Curcuma longa</Emphasis> extract) on LPS-induced acute lung injury is mediated by the activation of AMPK

Purpose

Curcumin, a biphenolic compound extracted from turmeric (Curcuma longa), possesses potent anti-inflammatory activity. The present study investigated whether curcumin could increase 5′ adenosine monophosphate-activated protein kinase (AMPK) activity in macrophages and modulate the severity of lipopolysaccharide (LPS)-induced acute lung injury.

Methods

Macrophages were treated with curcumin and then exposed (or not) to LPS. Acute lung injury was induced by intratracheal administration of LPS in BALB/c mice.

Results

Curcumin increased phosphorylation of AMPK and acetyl-CoA carboxylase (ACC), a downstream target of AMPK, in a time- and concentration-dependent manner. Curcumin did not increase phosphorylation of liver kinase B1, a primary kinase upstream of AMPK. STO-609, an inhibitor of calcium²⁺/calmodulin-dependent protein kinase kinase, diminished curcumin-induced AMPK phosphorylation, but transforming growth factor-beta-activated kinase 1 inhibitor did not. Curcumin also diminished the LPS-induced increase in phosphorylation of inhibitory κB-alpha and the production of tumor necrosis factor alpha (TNF-α), macrophage inflammatory protein (MIP)-2, and interleukin (IL)-6 by macrophages. Systemic administration of curcumin significantly decreased the production of TNF-α, MIP-2, and IL-6 as well as neutrophil accumulation in bronchoalveolar lavage fluid, and also decreased pulmonary myeloperoxidase levels and the wet/dry weight ratio in mice subjected to LPS treatment.

Conclusion

These results suggest that the protective effect of curcumin on LPS-induced acute lung injury is associated with AMPK activation.

     

Effect of cooled hyperbaric bupivacaine on unilateral spinal anesthesia success rate and hemodynamic complications in inguinal hernia surgery

Purpose

We hypothesized that cooling hyperbaric bupivacaine from 23 to 5 °C may limit the intrathecal spread of bupivacaine and therefore increase the success rate of unilateral spinal anesthesia and decrease the rate of hemodynamic complications.

Methods

A hundred patients scheduled for elective unilateral inguinal hernia surgery were randomly allocated to receive 1.8 ml of 0.5 % hyperbaric bupivacaine intrathecally at either 5 °C (group I, n = 50) or at 23 °C (group II, n = 50). Following spinal block at the L2-3 interspace, the lateral decubitus position was maintained for 15 min. Unilateral spinal anesthesia was assessed and confirmed at 15 and 30 min. The levels of sensory and motor block on the operative side were evaluated until complete resolution.

Results

The rate of unilateral spinal anesthesia at 15 and 30 min was significantly higher in group I (p = 0.015 and 0.028, respectively). Hypotensive events and bradycardia were significantly rarer in group I (p = 0.014 and 0.037, respectively). The density and viscosity of the solution at 5 °C was significantly higher than at 23 °C (p < 0.0001). Compared with group II, sensory block peaked later in group I (17.4 vs 12.6 min) and at a lower level (T9 vs T7), and two-segment regression of sensory block (76.4 vs 84.3 min) and motor block recovery was shorter (157.6 vs 193.4 min) (p < 0.0001).

Conclusions

Cooling of hyperbaric bupivacaine to 5 °C increased the density and viscosity of the solution and the success rate of unilateral spinal anesthesia, and decreased the hemodynamic complication rate.

     

The efficacy of continuous subcostal transversus abdominis plane block for analgesia after living liver donation: a retrospective study

Purpose

Postoperative pain management for living liver donors has become a major concern as a result of the increasing number of living liver donations. Transversus abdominis plane (TAP) block has been known to provide effective analgesia for abdominal surgery. The aim of this study was to evaluate the efficacy of ultrasound-guided continuous subcostal TAP block as a part of a multimodal analgesic regimen in comparison with conventional intravenous (IV) fentanyl-based analgesia in living liver donors.

Methods

Thirty-two donors were retrospectively classified into either the continuous subcostal TAP block group (TAP group) or the IV fentanyl-based analgesia group (control group). TAP group donors received bilateral continuous subcostal TAP infusion of 0.125 % levobupivacaine at 6 ml/h. Control group donors did not receive any neural blockade.

Results

Cumulative fentanyl consumption was significantly lower in the TAP group for 48 h (P < 0.01) as compared to the control group. Further, the donors in the TAP group had significantly lower incidence of nausea and vomiting during 24–48 h postoperatively (P < 0.01) and fewer delays in the initiation of oral intake than those in the control group (P = 0.02).

Conclusions

In conclusion, continuous subcostal TAP block provided an effective opioid-sparing analgesia for living liver donors.

     

Predictors of postoperative pain and analgesic requirements following abdominal hysterectomy: an observational study

Purpose

A prospective observational study is conducted to identify independent predictors of pain and morphine consumption following abdominal hysterectomy.

Methods

Preoperative State Trait Anxiety Inventory (STAI), Numerical Rating Scales (NRS) for anxiety and pain expectations, thermal pain thresholds and pain scores at forearm and incision site, and pain scores generated from the insertion of an intravenous catheter were measured in female patients undergoing abdominal hysterectomy. Pearson correlations between the predictors and the two outcome measures postoperative pain scores and morphine consumption were studied and multiple regression analysis was conducted to identify independent predictors (primary outcome). Secondary outcomes included cut-off values of predictive tools for morphine consumption.

Results

Data from 60 patients were analyzed. STAI state anxiety, NRS pain expectations, and NRS anxiety scores were identified as independent predictors of postoperative morphine consumption. We identified a cut-off value of 4.5 (sensitivity 90 %, specificity of 60 %) for the NRS anxiety and a cut-off of 42.5 (sensitivity 70 %, specificity 70 %) for the state anxiety STAI score for increased postoperative morphine consumption.

Conclusions

Preoperative STAI state anxiety scores and NRS pain expectations are independent predictors for increased morphine consumption following hysterectomy. The STAI state anxiety tool and NRS 0-10 anxiety tool can be used interchangeably. The NRS 0-10 anxiety is a much simpler tool than STAI state anxiety and is associated with a higher sensitivity for high morphine consumption. Thermal pain thresholds and IV pain scores were not predictive of postoperative morphine consumption.

     

The comparison of adductor canal block with femoral nerve block following total knee arthroplasty: a systematic review with meta-analysis

Purpose

Although several studies have compared the clinical efficacy of an adductor canal block (ACB) to that of a femoral nerve block (FNB) for analgesia after total knee arthroplasty (TKA), disputes mainly exist in the recovery of quadriceps strength and mobilization ability between the two methods. The aim of the present study was to compare, in a systematic review and meta-analysis, the clinical efficacy of ACB with that of FNB.

Methods

We systematically searched randomized controlled trials comparing FNB with ACB for analgesia after TKA in Pubmed and the Cochrane Library from inception to April 30th 2015. There was no limitation of publication language. Trial quality was assessed using the modified Jadad scale, and eligible data were pooled for meta-analysis.

Results

Five studies of 348 patients were included. Outcomes showed that patients who received ACB had similar or better recovery of quadriceps strength and mobilization ability than those that underwent FNB. Similar efficacy was found between the two strategies regarding adductor strength, pain scores [at rest (p = 0.86), at or after knee flexion (p = 0.31)], opioid consumption (p = 0.99), opioid-associated adverse effects (p = 0.60), length of hospital stay (p = 0.42), patient satisfaction (p = 0.57), and success rate of blockade (p = 0.20).

Conclusions

The present study suggests that TKA patients who receive ACB can achieve similar or even better recovery of quadriceps strength and mobilization ability than those treated with FNB. Taken as a whole, ACB may be a better analgesia strategy after TKA at present.