An open and shut case for early VATS treatment of primary spontaneous pneumothorax in children

BACKGROUND: Treatment of primary spontaneous pneumothorax (SP) involves thoracostomy tube (TT) drainage, with surgery reserved for persistent or recurrent air leaks. We hypothesized that the advent of video-assisted thoracic surgery (VATS) would change indications and outcomes for surgical treatment of SP in our centre. METHODS: We performed a retrospective (1993-2003) review of children treated for SP. Patients with persistent or recurrent air leaks underwent either limited axillary thoracotomy (LAT), 1993-2001, or VATS, 2001-2003. We included the following outcomes: preoperative SP episodes, TT days (that is, patient days with TT in situ, before surgery), length of hospital stay (LOS), narcotic use and freedom from recurrence. We evaluated the predictive value of preoperative CT scans in guiding treatment of the contralateral side. RESULTS: Among 31 patients with 19 ipsilateral or contralateral recurrences (61%), 11 were managed nonoperatively. Twenty-six surgeries (13 LAT, 13 VATS) were performed in 20 patients, with 9 undergoing bilateral procedures (3 LAT, 6 VATS). VATS patients were treated earlier, had a diminished narcotic requirement postoperatively and had a shorter LOS with an equivalent recurrence rate, compared with LAT patients. The absence of contralateral blebs did not predict freedom from SP on the contralateral side in patients undergoing surgery for ipsilateral SP. CONCLUSIONS: Compared with LAT, VATS causes less pain, has a shorter LOS and encourages earlier surgical treatment (including prophylactic, contralateral treatment) of SP in children.     

Morphologic Analysis of the Carpal Tunnel and Median Nerve Following Open and Endoscopic Carpal Tunnel Release

Background: Endoscopic carpal tunnel release (ECTR) has purported advantages over open release such as reduced intraoperative dissection and trauma and more rapid recovery. Endoscopic carpal tunnel release has been shown to have comparable outcomes to open release, but open release is considered easier and safer to perform. Previous studies have demonstrated an increase in carpal tunnel volume, regardless of the technique used. However, the mechanism by which this volumetric increase occurs has been debated. Our study will determine through magnetic resonance imaging (MRI) analysis the morphologic changes that occur in both open carpal tunnel release (OCTR) and ECTR, thereby clarifying any morphologic differences that occur as a result of the 2 operative techniques. We hypothesize that there will be no morphologic differences between the 2 techniques. Methods: This was a prospective study to compare the postoperative anatomy of both techniques with MRI. Nineteen patients with clinical and nerve conduction study–confirmed carpal tunnel syndrome underwent either open or endoscopic release. Magnetic resonance imaging was performed preoperatively and 6 months postoperatively in all patients to examine the volume of the carpal tunnel, transverse distance, anteroposterior (AP) distance, divergence of tendons, and Guyon’s canal transverse and AP distance. Results: There was no significant difference in the postoperative morphology of the carpal tunnel and median nerve between OCTR and ECTR at 6-month follow-up on MRI. Conclusion: We conclude that there are no morphologic differences in OCTR and ECTR. It is an increase in the AP dimension that appears to be responsible for the increase in the volume of the carpal tunnel.     

Postoperative arrhythmias in colorectal surgical patients: incidence and clinical correlates

OBJECTIVE: To determine the incidence and clinical correlates of postoperative cardiac arrhythmias in patients undergoing elective large bowel resection. METHODS: Fifty-one consecutive patients undergoing elective open colorectal resection were recruited for this prospective observational study. Participating patients underwent daily three-lead electrocardiograms postoperatively. Data regarding potential risk factors for arrhythmias were recorded. Post-operative complications were recorded. RESULTS: Thirteen (26%) patients developed a postoperative arrhythmia, most commonly atrial fibrillation. Significant univariate correlates with postoperative arrhythmias were: age (P<0.01), hypertension (P<0.01), pre-operative serum potassium levels (P<0.01), postoperative pulmonary oedema (P=0.03), postoperative serum potassium (P=0.03) and sodium (P<0.01). Arrhythmia patients were more likely to have other complications (P=0.02). Thirty-one percent of arrhythmia patients had underlying sepsis compared with 18% of controls (P=0.38). CONCLUSION: Arrhythmias are common following elective large bowel resection. They occur in older patients and are associated with the development of other complications.     

Coccidioidomycosis After Renal Transplantation in an Endemic Area

Coccidioidomycosis is an endemic fungal infection of the desert southwestern United States of particular concern for immunosuppressed renal transplant recipients. The clinical course of coccidioidomycosis can be severe in immunosuppressed patients, with high rates of dissemination and mortality, and antifungal prophylaxis is routinely administered to high-risk patients. We sought to determine the impact of coccidioidomycosis on patients who received their renal transplant at our hospital in Phoenix, Arizona. A retrospective records review of the first 205 patients who received a renal transplant between June 1999 and December 2003 identified 6 patients (3%) who had contracted coccidioidomycosis after transplantation. All six cases occurred more than 6 months after transplantation. Two of these six patients had disseminated coccidioidomycosis. Two patients, one with pulmonary infection and one with disseminated infection, died. None of the six patients with coccidioidomycosis after transplantation had identified risk factors before transplantation. No high-risk patient who received targeted antifungal prophylaxis had a reactivation of coccidioidomycosis after transplantation. Treatment for acute rejection and induction with antithymocyte globulin did not appear to increase the risk of subsequent coccidioidomycosis.     

Clinical review: Healing in gastrointestinal anastomoses, part I

Gastrointestinal healing is a topic rarely reviewed in the literature, yet it is of paramount importance to the surgeon. Failure of anastomotic healing may lead to life-threatening complications, additional surgical procedures, increased length of stay, increased cost, long-term disability, and reduced quality of life for the patient. The goal of this article is to review the biological response to wounded tissue, to outline discrete differences between skin and gastrointestinal healing, to discuss local and systemic factors important to gastrointestinal healing, and to compare methods of measuring collagen content and strength of the newly formed anastomosis. Part II of this review will focus on techniques and therapies available to optimize anastomotic healing.     

Cannabinoids: is there a potential treatment role in epilepsy?

Cannabinoids have been used medicinally for centuries, and in the last decade, attention has focused on their broad therapeutic potential particularly in seizure management. While some cannabinoids have demonstrated anticonvulsant activity in experimental studies, their efficacy for managing clinical seizures has not been fully established. This commentary will touch on our understanding of the brain endocannabinoid system’s regulation of synaptic transmission in both physiological and pathophysiological conditions, and review the findings from both experimental and clinical studies on the effectiveness of cannabinoids to suppress epileptic seizures. At present, there is preliminary evidence that non-psychoactive cannabinoids may be useful as anticonvulsants, but additional clinical trials are needed to fully evaluate the efficacy and safety of these compounds for the treatment of epilepsy.