Time to reintroduction of feeding in infants with nonsurgical necrotizing enterocolitis

Background

For infants with necrotizing enterocolitis (NEC) treated nonoperatively, no consensus exists on the optimal fasting period prior to reintroducing feeds after NEC. We report our experience with early (< 7 days) and late (≥ 7 days) refeeding in this population.

Pectoralis major transfer for anterior-superior subluxation in massive rotator cuff insufficiency

The purpose of this study was to evaluate the outcome after subcoracoid pectoralis major transfer for anterior-superior shoulder instability in massive rotator cuff insufficiency. Fourteen patients underwent subcoracoid pectoralis major transfer for this debilitating surgical complication. At a mean 17.5-month follow-up, there were 11 satisfactory and 3 unsatisfactory results. Nine of the patients were satisfied with the procedure and would repeat the operation under similar circumstances. Pain scores, as measured on a visual analog scale, decreased from 6.9 to 3.2 postoperatively. Mean forward flexion increased from 24.4 degrees to 60.8 degrees. American Shoulder and Elbow Society functional outcome score increased from 27.2 preoperatively to 47.7 postoperatively. Thirteen of the fourteen patients had improved humeral head containment and improved ability to perform activities of daily living at waist level. A subcoracoid pectoralis major muscle transfer has a low complication rate and is a viable option in this difficult patient population, with better results than those previously reported.     

The correlation between fundamental characteristics and first-time performance in laparoscopic tasks

Background

The ability of characteristics to predict first time performance in laparoscopic tasks is not well described. Videogame experience predicts positive performance in laparoscopic experiences but its mechanism and confounding-association with aptitude remains to be elucidated. This study sought to evaluate for innate predictors of laparoscopic performance in surgically naive individuals with minimal videogame exposure.

A comparative study on the accuracy of pedicle screw placement assisted by personalized rapid prototyping template between pre- and post-operation in patients with relatively normal mid-upper thoracic spine

Purpose

The aim of this study was to assess the accuracy of rapid prototyping drill template technique for placing pedicle screws in the mid-upper thoracic vertebrae in clinics.

Methods

151 consecutive patients underwent thoracic instrumentation and fusion for a total of 582 pedicle screws placed in the mid-upper thoracic vertebrae. Using computer software, the authors constructed drill templates that fit onto the posterior elements of the mid-upper thoracic vertebrae with drill guides designed to instrument the pedicles. The start point and three dimensional location of the planned and inserted screws were measured and compared.

Results

Grading of the CT scans revealed 559 (96.1 %) out of 582 screws completely within the desired pedicle. The direction of pedicle violation included 5 medial, 2 airball, and 16 lateral. The paired t test suggested that these results were statistically significant in more than half of the locations (T1-left-TA(P = 0.024), T2-left-SA(P = 0.031), T3-left-SA(P = 0.014), T4-left-TA(P = 0.004), T5-left-TA(P = 0.034), T7-left-TA(P = 0.000). T1-right-TA(P = 0.049), T2-right-TA(P = 0.044), T3-right-TA(P = 0.014), T5-right-TA(P = 0.013)). The paired t-test suggested that these results were statistically significant at several locations (T4-left-Δy(P = 0.041), T5-left-Δx(P = 0.016), T3-right-Δy(P = 0.015)).

Conclusion

Use of a rapid prototyping drill template to assist in the placement of mid and upper thoracic pedicle screws may lead to increased accuracy. This patient specific technology must be combined with an understanding of the patients’ anatomy and carefully secured to the posterior elements intraoperatively to avoid nerve or vascular complications.

     

Oncologic and Perioperative Outcomes Following Selective Application of Laparoscopic Pancreaticoduodenectomy for Periampullary Malignancies

Background

Data are sparse regarding patient selection criteria or evaluating oncologic outcomes following laparoscopic pancreaticoduodenectomy (LPD). Having prospectively limited LPD to patients with resectable disease defined by National Comprehensive Cancer Network (NCCN) criteria, we evaluated perioperative and long-term oncologic outcomes of LPD compared to a similar cohort of open pancreaticoduodenectomy (OPD).

Methods

Consecutive patients (November 2010–February 2014) undergoing pancreaticoduodenectomy (PD) for periampullary adenocarcinoma were reviewed. Patients were excluded from further analysis for benign pathology, conversion to OPD for portal vein resection, and contraindications for LPD not related to their malignancy. Outcomes of patients undergoing LPD were analyzed in an intention-to-treat manner against a cohort of patients undergoing OPD.

Results

These selection criteria resulted in offering LPD to 77 % of all cancer patients. Compared to the OPD cohort, LPD was associated with significant reductions in wound infections (16 vs. 34 %; P?=?0.038), pancreatic fistula (17 vs. 36 %; P?=?0.032), and median hospital stay (9 vs. 12 days; P?=?0.025). Overall survival (OS) was not statistically different between patients undergoing LPD vs. OPD for periampullary adenocarcinoma (median OS 27.9 vs. 23.5 months; P?=?0.955) or pancreatic adenocarcinoma (N?=?28 vs. 22 patients; median OS 20.7 vs. 21.1 months; P?=?0.703).

Conclusions

The selective application of LPD for periampullary malignancies results in a high degree of eligibility as well as significant reductions in length of stay, wound infections, and pancreatic fistula. Overall survival after LPD is similar to OPD.

     

Adrenomedullin is increased in the portal circulation during chronic sepsis in rats

BACKGROUND: A clinical hallmark of sepsis is an early, hyperdynamic cardiac phase (increased cardiac output) that degrades to a hypodynamic phase, which results in poor gut perfusion and subsequent gastrointestinal (GI) hypoxemia, tissue ischemia, necrosis and loss of gut barrier function. Studies in rat cecal-ligation and puncture suggest that the potent vasodilator adrenomedullin (AM) might initiate or maintain the hypodynamic phase. We hypothesize that AM expression is increased in acute Escherichia coli bacteremia and chronic E coli-Bacteroides fragilis sepsis. METHODS: Acute bacteremia: male Sprague-Dawley rats were anesthetized (urethane/alpha-chloralose), tracheotomized, and cannulated for monitoring blood pressure (MABP) and heart rate (HR) and for infusion of E coli (10(9) colony-forming units [CFU] E coli per 1 mL normal saline) and blood sampling. Arterial blood was withdrawn for arterial blood gas (ABG) measurements every 60 minutes. After 6 hours, we harvested lung, liver, kidney, spleen, and small intestine tissue samples and drew arterial and portal blood for AM enzyme-linked immunosorbent assay (ELISA). Chronic sepsis: a sterile gauze pad was implanted and animals recovered for 5 days. Twenty-four hours (10(9) CFU E coli and 10(9) CFU B fragilis per 1 mL normal saline; 1 injection) or 72 hours (2 injections) after the inoculation of the back sponge, rats were anesthetized, intubated, and cannulated as above. MABP, HR, and ABG were measured for 1 hour before tissue and serum harvest for AM ELISA. RESULTS: Sepsis increased HR and MABP in all groups. Acute sepsis caused a respiratory alkalosis and pH was also elevated in chronic sepsis. Serum AM levels were increased in all groups compared with baseline and remained elevated at every time point, but were not different between saline controls and septic animals at any time point, except for the portal serum from the 72-hour chronic sepsis, which was elevated. CONCLUSIONS: These data suggest that surgical manipulation alone is sufficient to stimulate AM secretion, most probably from endothelial cells. While the AM levels were decreasing at 72 hours compared with 6 hours or 24 hours in the arterial blood and the saline control portal blood, it remained elevated in the septic portal samples, suggesting that the sepsis-induced increase of AM was derived from the gut by a different mechanism than that which elevated arterial serum levels.