Modified Technique of Pancreaticojejunal Anastomosis with Invagination Following Pancreaticoduodenectomy: A Cohort Study

BACKGROUND: Leakage from pancreatic anastomoses remains the single most important morbidity after pancreaticoduodenectomy and contributes to prolonged hospitalization and mortality. This observational cohort study reported the surgical outcome of a modified invagination technique of pancreaticojejunostomy after pancreaticoduodenectomy. METHODS: Between December 2001 and December 2007, a total of 52 consecutive patients underwent elective pancreaticoduodenectomy for benign or malignant pathologies of the pancreas or the periampullary region in a tertiary referral center. All patients underwent our modified invagination technique of pancreaticojejunostomy regardless of the characteristics of the pancreatic stump. Data were collected prospectively. RESULTS: The mean hospital stay was 12.6 +/- 3.2 days. The incidence of overall surgical complications was 9.6%. No patient developed pancreatic fistula. One patient (1.9%) died of respiratory failure on postoperative day 7. CONCLUSIONS: We reported our pancreaticojejunostomy anastomosis technique with a pancreatic fistula rate of 0% and low intra-abdominal complication rate. The favorable results of this technique warrant further investigation in large prospective cohort studies and prospective randomized controlled studies.     

Selective parathyroid auto‐transplantation during thyroidectomy

Aim: Permanent hypoparathyroidism is a debilitating morbidity following thyroidectomy and parathyroid auto‐transplantation has been shown to be effective in preventing permanent hypoparathyroidism. Controversy exists regarding the benefit of routine versus selective auto‐transplantation. We evaluate the outcome of selective parathyroid auto‐transplantation in our hospital. Methods: A retrospective study was conducted to assess the incidence of postoperative hypocalcaemia. Indication for parathyroid auto‐transplant was doubtful viability of parathyroid gland during thyroidectomy. From 1 July 2000 to 30 June 2005, all patients who underwent total, subtotal and completion thyroidectomy were included. Other outcome measures including recurrent laryngeal nerve injury and operative time were also analyzed. Results: A total of 170 bilateral or completion thyroidectomies were performed within this period. Total, subtotal, and completion total thyroidectomies were performed in 103 (60.6%), 62 (36.5%), and five (2.9%) patients, respectively. Median age was 45 years (range 19–82). One hundred and twenty‐four patients (73%) had benign thyroid disease, and 46 patients (27%) had thyroid carcinoma. Parathyroid auto‐transplant was performed in 35 patients (20.6%). Mean operation time was 204 min (range 95–510 min). There was no difference in the operation time between the patients with parathyroid auto‐transplant and those without auto‐transplant (217 vs 200 min, P = 0.229). Transient hypocalcaemia occurred in 31 patients (18.2%) whereas two patients had permanent hypocalcaemia (1.2%). Permanent recurrent laryngeal nerve injury occurred in one patient (0.6%). Conclusions: The adoption of selective parathyroid auto‐transplant during thyroidectomy achieves an extremely low incidence of permanent hypoparathyroidism without excessive transient hypoparathyroidism.     

Complete worldwide operative experience in laparoscopic diaphragm pacing: results and differences in spinal cord injured patients and amyotrophic lateral sclerosis patients

Background  Diaphragm movement is essential for adequate ventilation, and when the diaphragm is adversely affected patients face lifelong positive-pressure mechanical ventilation or death. This report summarizes the complete worldwide multicenter experience with diaphragm pacing stimulation (DPS) to maintain and provide diaphragm function in ventilator-dependent spinal cord injury (SCI) patients and respiratory-compromised patients with amyotrophic lateral sclerosis (ALS). It will highlight the surgical experiences and the differences in diaphragm function in these two groups of patients. Methods  In prospective Food and Drug Administration (FDA) trials, patients underwent laparoscopic diaphragm motor point mapping with intramuscular electrode implantation. Stimulation of the electrodes ensued to condition and strengthen the diaphragm. Results   From March of 2000 to September of 2007, a total of 88 patients (50 SCI and 38 ALS) were implanted with DPS at five sites. Patient age ranged from 18 to 74 years. Time from SCI to implantation ranged from 3 months to 27 years. In 87 patients the diaphragm motor point was mapped with successful implantation of electrodes with the only failure the second SCI patient who had a false-positive phrenic nerve study. Patients with ALS had much weaker diaphragms identified surgically, requiring trains of stimulation during mapping to identify the motor point at times. There was no perioperative mortality even in ALS patients with forced vital capacity (FVC) below 50% predicted. There was no cardiac involvement from diaphragm pacing even when analyzed in ten patients who had pre-existing cardiac pacemakers. No infections occurred even with simultaneous gastrostomy tube placements for ALS patients. In the SCI patients 96% were able to use DPS to provide ventilation replacing their mechanical ventilators and in the ALS studies patients have been able to delay the need for mechanical ventilation up to 24 months. Conclusion   This multicenter experience has shown that laparoscopic diaphragm motor point mapping, electrode implantation, and pacing can be safely performed both in SCI and in ALS. In SCI patients it allows freedom from ventilator and in ALS patients it delays the need for ventilators, increasing survival. Presented as an oral presentation at the Plenary Session of SAGES 2008 Scientific Session, Philadephia.     

Generalized low bone mass of girls with adolescent idiopathic scoliosis is related to inadequate calcium intake and weight bearing physical activity in peripubertal period

Generalized low bone mass has been well documented in patients with adolescent idiopathic scoliosis (AIS). However, studies linking calcium-intake (CA), weight-bearing physical-activity (PA) and bone mass of AIS are lacking. We aimed to study the relationship between CA, PA and bone mass in AIS girls and compared to those of healthy non-AIS controls during the peripubertal period. Newly diagnosed AIS girls (n=596) aged 11–16 years with Cobb angle 10° were recruited to compare with age-matched healthy girls (n=302) in a cross-sectional study. Anthropometric parameters, pubertal status, CA and PA were assessed. Areal bone mass of lumbar spine and femoral neck, and volumetric bone mass of distal radius and tibia were determined by dual-energy X-ray absorptiometry and peripheral quantitative computed tomography, respectively. The results showed that weight and body mass index (BMI) of AIS were lower than the controls (P<0.05). Corrected height and arm span of AIS were longer than those of controls from 13 years onwards (P<0.02). Median CA of AIS was <410 mg/day across the ages and did not differ from the controls (P=0.063). Median PA of AIS (1.6 h/day) was lower than the controls (1.8 h/day) (P=0.025). Bone mass of AIS was on average 6.5% lower than controls across the ages (P<0.05). CA and PA were significantly correlated with bone mass of AIS (P<0.04). Multivariate analysis showed that AIS in girls was associated with lower bone mass, and that both CA and PA were independent predictors of bone mass in AIS. In conclusion, AIS girls were found to have lower body weight and BMI, longer segmental lengths and generalized low bone mass. Inadequate calcium intake and weight-bearing physical activity were significantly associated with low bone mass in AIS girls during the peripubertal period. The importance of preventing generalized osteopenia in the control of AIS progression during the peribubertal period warrants further study.     

Survey of hospital doctors' attitudes and knowledge of oral conditions in older patients

The study was designed to assess the views and knowledge of hospital doctors in general and geriatric medicine on oral health in older people. Eighty two doctors in general and geriatric medicine at two hospitals were shown 12 colour slides of oral mucosal conditions and asked to give a diagnosis for each slide and complete a questionnaire. Completed questionnaires with the answers to the coloured slides were returned completed by 70 doctors. The majority of doctors (84%) felt it was important to examine older patients' mouths, however only 19% (chi(2) p=0.0001) routinely do so. If asked to prescribe nystatin by the nursing staff, 30% said they would do so without examining the mouth itself. Only 9% of doctors knew that wearing dentures was a specific risk factor for oral candidiasis (chi(2) p=0.001). Altogether 56% of doctors did not feel confident in examining the oral cavity and most (77%) did not think they had had sufficient training in this examination. Only two doctors correctly diagnosed all of the slides. An early squamous carcinoma was misdiagnosed by 80% of the doctors (chi(2) p=0.0001). Hospital doctors do not routinely inspect older patients' mouths. Even if shown slides of typical oral mucosal lesions many hospital doctors are unable to diagnose them. Issues on training need to be addressed. From the patients' point of view a public health campaign is required to educate older people on the need for a regular dental review and be aware that doctors may not be able to diagnose serious oral conditions.     

Prevention and treatment of pressure ulcers/injuries: The protocol for the second update of the international Clinical Practice Guideline 2019

Aim

The European Pressure Ulcer Advisory Panel, the Pan Pacific Pressure Injury Alliance, and the National Pressure Ulcer Advisory Panel are updating the ‘Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline’ (CPG) in 2019. The aim of this contribution is to summarize and to discuss the guideline development protocol for the 2019 update.

An unusual accessory pathway: anteroseptal to ventricular outflow region connection

Accessory pathways are typically located along the left or right atrioventricular junction. Distinct ventricular pre-excitation patterns determined by surface electrocardiography can provide reasonable pathway localization prior to invasive mapping and catheter ablation. We report an accessory pathway producing an unusual electrocardiographic appearance suggestive of ventricular outflow region pre-excitation. Pacing maneuvers and standard intracardiac recordings confirmed an atrial insertion immediately adjacent to the atrioventricular (AV) node and supported a ventricular insertion at the outflow tract region well away from the AV junction. The elimination of pathway conduction was achieved with radiofrequency (RF) energy at the atrial insertion after successful ice mapping excluded AV block at the target site. This is the second such pathway observed at our institution over a 20-year period.