Standards for Endovascular Neurosurgical Training and Certification of the Society of Korean Endovascular Neurosurgeons 2013

The need for standard endovascular neurosurgical (ENS) training programs and certification in Korea cannot be overlooked due to the increasing number of ENS specialists and the expanding ENS field. The Society of Korean Endovascular Neurosurgeons (SKEN) Certification Committee has prepared training programs and certification since 2010, and the first certificates were issued in 2013. A task force team (TFT) was organized in August 2010 to develop training programs and certification. TFT members researched programs and systems in other countries to develop a program that best suited Korea. After 2 years, a rough draft of the ENS training and certification regulations were prepared, and the standard training program title was decided. The SKEN Certification Committee made an official announcement about the certification program in March 2013. The final certification regulations comprised three major parts: certified endovascular neurosurgeons (EN), certified ENS institutions, and certified ENS training institutions. Applications have been evaluated and the results were announced in June 2013 as follows: 126 members received EN certification and 55 hospitals became ENS-certified institutions. The SKEN has established standard ENS training programs together with a certification system, and it is expected that they will advance the field of ENS to enhance public health and safety in Korea.     

Risk factors of delayed surgical evacuation for initially nonoperative acute subdural hematomas following mild head injury

Background

Although the majority of patients with minimal acute subdural hematomas (aSDHs) can be managed conservatively, some require delayed aSDH evacuation due to hematoma enlargement. This study was designed to determine the risk factors associated with delayed hematoma enlargement leading to surgery in patients with aSDHs who did not initially require surgical intervention.

Methods

From 2002 to 2012, 98 patients were treated for nonoperative aSDHs following mild head injury (Glasgow Coma Scale scores of 13–15). The outcome variables were radiographic evidence of SDH enlargement on serially obtained computed tomography (CT) images and later surgical evacuation. Univariate and multivariate analyses were applied to both the demographic and initial radiographic features to identify risk factors for SDH progression and surgery.

Results

Overall, 64 patients (65 %) revealed minimal SDH or spontaneous hematoma resolution (conservative group) with conservative management at their last follow-up CT scan. The remaining 34 patients (35 %) received delayed hematoma evacuation (delayed surgery group) a median of 17 days after the head trauma. There were no significant differences between the two groups for baseline characteristics, including age, injury type, degree of brain atrophy, prior history of antithrombotic drugs, and coagulopathy. The presence of cerebral contusions and subarachnoid hemorrhages was more common in the conservative group (p?=?0.003 and p?=?0.003, respectively). On multivariate analysis, hematoma volume (p?=?0.01, odds ratio [OR]?=?1.094, 95 % confidence interval [CI]?=?1.021–1.173) and degree of midline shift (p?=?0.01, OR?=?1.433, 95 % CI?=?1.088–1.888) on the initial CT scan were independently associated with delayed hematoma evacuation.

Conclusions

A critical proportion of patients with minimal aSDHs occurring after mild head injury can progress over several weeks and require hematoma evacuation. Especially patients with a large initial SDH volume and accompanying midline shift require careful monitoring of hematoma progression.     

Effects of magnesium sulphate on coagulation after laparoscopic colorectal cancer surgery,measured by rotational thromboelastometry (ROTEM®)

We investigated the effects of magnesium sulphate on blood coagulation profiles using rotational thromboelastometry in patients undergoing laparoscopic colorectal cancer surgery. Patients were randomly allocated to the magnesium group (n = 22) or control group (n = 22). The magnesium group received intravenous magnesium sulphate (50 mg.kg^?1 followed by a continuous infusion of 15 mg.kg^?1.h^?1), whereas the control group received the same volume of isotonic saline. Mean (SD) postoperative serum magnesium levels were 1.60 (0.13) mmol.l^?1 in the magnesium group compared with 0.98 (0.06) mmol.l^?1 in the control group (p < 0.001). All maximum clot firmness values of ROTEM analysis were significantly lower on the third postoperative day in the magnesium group compared with the control group (p < 0.05). We conclude that ROTEM analysis demonstrated that intra‐operative administration of intravenous magnesium sulphate reduces blood hypercoagulability in patients undergoing laparoscopic colorectal cancer surgery.     

Gasless laparoscopic assisted surgery for abdominal trauma

Background

Numerous studies have described the effectiveness of laparoscopy for trauma patients. In gas-filling laparoscopic surgery, most of the disadvantages are related to a positive pressure pneumoperitoneum that compromises the cardiopulmonary function. The main advantage of gasless laparoscopic assisted surgery (GLA) is that it does not affect the haemodynamic status, which is particularly critical for trauma patients. The purpose of this study was to investigate the feasibility and safety of GLA for abdominal trauma.

Materials and methods

This was a retrospective, 1:2 matched case–control study of all trauma gasless assisted laparoscopies performed from January 2010 until January 2013 in a Level I trauma centre. In total, 965 patients with abdominal trauma were admitted. According to the abdominal trauma protocol, a total of 93 hemodynamically stable patients required the operation; we selected fifteen patients to undergo GLA and matched 30 other patients to undergo laparotomy. Demographic information, perioperative findings, injury severity score, and postoperative recovery were recorded and analyzed.

Results

A total of fifteen patients (ten men, five women) with a mean age of 44.4, standard deviation (SD) 13.2 years underwent GLA for abdominal trauma. Eight patients had penetrating injuries, while seven had blunt injuries. Overall, 73% patients had multiple injuries. The mean time to the identified lesion was 23.1, SD 10.9 min, and the mean operative time was 109.7, SD 33.5 min. Most of the lesions were repaired concurrently by GLA. One conversion to laparotomy was done. The mean length of hospital stay (HLOS) was 9.1, SD 4.5 days. No mortality occurred in this series. The mean follow-up was 22.0, SD 7.9 months, and there were no significant events during this period. The mean operative times were comparable in the GLA and open surgery group (109.7, SD 33.5 vs. 131.2, SD 43.6 min; p = 0.076). Compared with the open surgery group, the HLOS was significantly shorter in the GLA group (9.1, SD 4.5 vs.16.3, SD 6.4 days; p = 0.030).

Conclusion

GLA offers both therapeutic and diagnostic advantages for patients with abdominal trauma. GLA shares the advantages of laparoscopy and prevents the cardiopulmonary function from being compromised due to pneumoperitoneum, which is especially critical for trauma patients.     

Citrulline levels following proximal versus distal small bowel resection

Purpose

Citrulline, a nonprotein amino acid synthesized by enterocytes, is a biomarker of bowel length and the capacity to wean from parenteral nutrition. However, the potentially variant effect of jejunal versus ileal excision on plasma citrulline concentration [CIT] has not been studied. This investigation compared serial serum [CIT] and mucosal adaptive potential after proximal versus distal small bowel resection.

Methods

Enterally fed Sprague-Dawley rats underwent sham operation or 50% small bowel resection, either proximal (PR) or distal (DR). [CIT] was measured at operation and weekly for 8 weeks. At necropsy, histologic features reflecting bowel adaptation were evaluated.

Results

By weeks 6–7, [CIT] in both resection groups significantly decreased from baseline (P < 0.05) and was significantly lower than the concentration in sham animals (P < 0.05). There was no difference in [CIT] between PR and DR at any point. Villus height and crypt density were higher in the PR than in the DR group (P ≤ 0.02).

Conclusion

[CIT] effectively differentiates animals undergoing major bowel resection from those with preserved intestinal length. The region of intestinal resection was not a determinant of [CIT]. The remaining bowel in the PR group demonstrated greater adaptive potential histologically. [CIT] is a robust biomarker for intestinal length, irrespective of location of small intestine lost.     

Antihyperalgesic effects of ginseng total saponins in a rat model of incisional pain

Background

The aim of this study was to assess whether intraperitoneal administration of ginseng total saponins (GTS) has antihyperalgesic effects in a rat model of incisional pain. The proinflammatory responses and reversal of the antihyperalgesic effect of GTS by N-methyl-d-aspartate (NMDA) or naloxone were also evaluated.

Materials and methods

Rats were injected intraperitoneally with 0.9% saline vehicle or various doses of GTS before or after a plantar incision. Paw withdrawal in response to application of the von Frey filament with the lowest bending force marked the mechanical withdrawal threshold (MWT). Blood samples were collected for the assessment of serum interleukin (IL)-1β and IL-6 levels. The IL levels were measured using an enzyme-linked immunosorbent assay kit. Rats were injected intraperitoneally with NMDA or naloxone before the GTS injection to assess the reversal of the antihyperalgesic effect of GTS.

Results

The MWT measured 2 h after the plantar incision increased significantly after the postincision administration of 50, 100, or 200 mg/kg of GTS compared with the MWT at 2 h after plantar incision. The MWT also increased significantly after the preincision injection of 100 or 200 mg/kg of GTS compared with the MWT of the vehicle control. Administration of GTS suppressed the postincision rise in serum IL-1β levels and NMDA inhibited the increase in the MWT compared with GTS alone.

Conclusions

Intraperitoneal administration of GTS before or after surgery induces antihyperalgesic effects in a rat model of incisional pain. The effects on mechanical hyperalgesia may be associated with anti-inflammatory cytokines and NMDA signaling.     

A movable microelectrode array for chronic basal ganglia single-unit electrocorticogram co-recording in freely behaving rats

The basal ganglia–cortical circuits are important for information process to brain function. However, chronic recording of single-unit activities in the basal ganglia nucleus has not yet been well established. We present a movable bundled microwire array for chronic subthalamic nucleus (STN) single-unit electrocorticogram co-recording. The electrode assembly contains a screw-advanced microdrive and a microwire array. The array consists of a steel guide tube, five recording wires and one referenced wire which form the shape of a guiding hand, and one screw electrode for cortico-recording. The electrode can acquire stable cortex oscillation-driven STN firing units in rats under different behaving conditions for 8 weeks. We achieved satisfying signal-to-noise ratio, portions of cells retaining viability, and spike waveform similarities across the recording sections. Using this method, we investigated neural correlations of the basal ganglia–cortical circuits in different behaving conditions. This method will become a powerful tool for multi-region recording to study normal statements or movement disorders.