Laparoscopic versus non-laparoscopic-assisted ventriculoperitoneal shunt placement in adults. A retrospective analysis

BACKGROUND: Ventriculoperitoneal shunts and distal shunt revisions bear a high risk of distal malfunction, especially in patients with previous abdominal pathologies as well as in obese patients. We performed laparoscopy-guided distal shunt placement or revision for patients with and without a positive abdominal history. We review the indications, techniques, complications, and long-term outcomes of these cases and compare the results to those of patients operated without laparoscopic guidance. METHODS: A total of 211 distal shunt procedures were performed in our institute between January 2001 and December 2005, 59 of which were laparoscopically guided, and 152 were not. Of the 211 procedures, 177 were placement of new shunt systems, and 34 were distal revisions. A total of 33 procedures were performed in 25 patients with a history of abdominal surgery or inflammatory bowel disease; 15 procedures were operated with laparoscopic guidance. RESULTS: The short-term complication and outcome rates were similar between the laparoscopy group and the other patients. Among the patients with new shunts, the long-term distal malfunction rate was lower in the laparoscopy group compared with the nonlaparoscopy group (4% vs 10.3%, respectively; P = .17). No patients in the laparoscopy group and 6 patients operated by other techniques had distal malfunction. There was 1 laparoscopy-related mortality and no morbidity. CONCLUSIONS: Laparoscopy is not routinely indicated in distal shunt placement or revision. However, a laparoscopy-guided procedure may lower the rate of distal malfunction in patients with previous abdominal surgeries.     

Postoperative apnea, respiratory strategies, and pathogenesis mechanisms: a review

Recovery from anesthesia is ideally routine and uneventful. After extubation, the recovering postoperative patient ought to breathe without supportive care or additional oxygenation. It has been demonstrated in previous studies that postoperative pulmonary complications are clinically relevant in terms of mortality, morbidity, and length of hospital stay. Compromised postoperative ventilation can be described as the condition in which the postoperative patient does not have satisfactory spontaneous ventilation support and adequate oxygenation. Causes of impaired ventilation, oxygenation, and airway maintenance can be mechanical, hemodynamic, and pharmacologic. This review describes prevalence and differential diagnosis, including co-morbidities of postoperative apnea. The physiological mechanisms of breathing and prolonged postoperative apnea are also reviewed; these mechanisms include influences from the brainstem, the cerebral cortex, and chemoreceptors in the carotid and aortic body. Causes of prolonged postoperative apnea and management are also discussed.     

Abstracts

Abstract

The efficacies of four bowel care regimens (bisacodyl suppositories, glycerin suppositories, mineral oil enemas and docusate sodium mini-enemas) were compared in seven subjects with traumatic spinal cord injury. Efficacy was assessed in terms of colonic transit time, bowel evacuation time and subjective responses to a questionnaire. Both docusate sodium mini-enemas and mineral oil enemas decreased total and left-sided colonic transit time. However, docusate sodium mini-enemas were superior to mineral oil enemas in terms of the decrease in bowel evacuation time and symptom reduction. Results in this small group of subjects suggest that docusate sodium mini-enemas may have advantages in the management of bowel evacuation in individuals with spinal cord injury. (J Spinal Cord Med 1998;21 -24)     

Bilateral brachial plexus block

Bilateral regional anesthesia techniques in general and bilateral brachial plexus blocks in particular are rarely performed because they have few clinical indications. We present the case of a patient who presented to the operating room for bilateral upper extremity procedures where we thought regional anesthesia was appropriate. The anesthesia management is discussed as well as potential problems and complications. IMPLICATIONS: Reports on bilateral regional blocks are extremely rare in the literature. Whereas they have the potential for more complications than a single technique, they can be very useful in specific clinical situations.     

GSTP1, GSTM1, and GSTT1 genetic polymorphisms in patients with cryptogenic liver cirrhosis

We investigated glutathione S-transferase (GST) P1I le (105) Val, T1, and M1 polymorphisms in 45 patients with documented cryptogenic cirrhosis and 56 healthy control subjects. Polymerase chain reaction-based procedures were performed in the studied populations to confirm the genotypes of GSTT1, M1, and P1. Ile/Val and Val/Val GSTP1 genotypes were more frequent in the patients with cirrhosis (n = 39, 87%) than in the control subjects (n = 10; 18%) (odds ratio [OR] 34.04; 95% confidence interval [CI] 10.70 to 108.31, P < 0.001). Among these patients with cirrhosis, 16 were heterozygous and 23 were homozygous, whereas only one person in the control group was homozygous. The GSTM1 null genotype was also more prevalent in cirrhotic patients than in healthy control subjects (OR 6.83, 95% CI 2.53 to 18.42, P < 0.001). The rate of GSTT1 deletion did not show a significant difference between the two groups (OR 2.35, 95% CI 0.76 to 7.28, P = 0.111). To our knowledge, this is the first evidence that GSTP1 and GSTM1 polymorphisms may be related to the development of cirrhosis by unknown mechanisms. The significant association of cryptogenic cirrhosis with Val/Val GSTP1 genotype encoding a low detoxification activity protein implicates this polymorphism as a risk factor for the occurrence of the disease. Presented as an abstract at the Forty-Fourth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Florida, May 19–22, 2003 (Poster of Distinction).     

Accuracy of computed tomography in assessing thoracic pedicle screw malposition

OBJECTIVE: Transpedicular instrumentation of the thoracic spine is potentially dangerous because of the close proximity of vital structures and the morphologic variability seen. Computed tomography has become the gold standard in evaluating the position of thoracic pedicle screws in vivo. Unfortunately, despite its common use, the accuracy of computed tomography has not been adequately investigated. The objective of this work was to evaluate the accuracy of computed tomography in evaluating the position of thoracic pedicle screws. METHODS: One hundred ninety-four thoracic pedicles in nine cadaveric specimens were instrumented and evaluated postoperatively with computed tomography and open dissection. Computed tomography films were assessed by three blinded observers who noted the position of each pedicle screw on two separate occasions. These data were subsequently compared with the open dissection data. RESULTS: Computed tomography was found to be 76 +/- 16% sensitive and 75 +/- 13% specific when compared with open dissection. Overall accuracy was 76 +/- 8%. Intraobserver accuracy was 79 +/- 5% in assessing thoracic pedicle screws by computed tomography. Fair to moderate degree of agreement was demonstrated for both interobserver and intraobserver data using kappa values. CONCLUSIONS: Computed tomography was found to be relatively insensitive in assessing thoracic pedicle screw position. In the face of postoperative complications, surgical exploration and hardware removal may still be necessary despite negative computed tomography.     

Polyphloretin phosphate, an antagonist of thyrotropin action: evidence for an interaction with the hormone rather than the receptor

Polyphloretin phosphate (PPP) is known to be an inhibitor of bovine TSH (bTSH)-induced stimulation of the thyroid in both in vivo and in vitro assays. The present studies were undertaken to delineate the mechanism of these effects. A high molecular weight PPP preparation strongly inhibited both the binding of 125I-labeled bTSH [( 125I]bTSH) to human thyroid membranes and the stimulation of adenylate cyclase evoked by bTSH therein. Inhibition of bTSH-induced adenylate cyclase activity by PPP was evident both in the absence and the presence of NaCl (150 mM) in the incubation medium. Incubation of membranes with PPP, followed by its removal, did not affect subsequent binding of [125I]bTSH, indicating that PPP did not bind firmly to or damage the TSH receptor. Gel chromatography on Sephadex G-100 revealed that [125I]bTSH incubated with PPP eluted earlier than [125I]bTSH alone, indicating that PPP had formed a higher molecular weight complex with [125I]bTSH. This effect could be prevented by the addition of an excess of unlabeled bTSH to the incubation mixture. Binding of [125I] bTSH in the higher molecular weight peak generated by incubation with PPP was less than half that in control specimens of [125I]bTSH. Studies with PPP were also conducted in a highly sensitive assay that employs cultured porcine thyroid cells and measures the cAMP response induced by bTSH. The inhibitory effect of PPP on bTSH-induced cAMP accumulation was also evident in this assay. However, the presence of divalent cations Ca++ and Mg++ in the assay medium greatly diminished the inhibitory effect of PPP. Similarly, addition of Ca++ and Mg++ to the incubation medium greatly reduced or abolished the inhibitory effect of PPP on [125I]bTSH binding. Both effects of these salts to lessen the inhibitory response to PPP were overcome by increasing the PPP concentration. Gel chromatographic studies revealed that Ca++ and Mg++ acted by inhibiting the formation of the high molecular weight complex of bTSH and PPP. From these findings, we conclude that PPP exerts its inhibitory effect on TSH-induced stimulatory responses in the thyroid, in vivo as well as in vitro, by forming a complex with the hormone. The complex either does not bind to TSH receptors or does so with much lower affinity.     

The active principles of plant extracts with antithyrotropic activity: oxidation products of derivatives of 3,4-dihydroxycinnamic acid

We have recently reported that freeze-dried extracts (FDE) of certain plants form high molecular weight adducts with bovine TSH (bTSH), preventing it from binding to and stimulating adenylate cyclase in human thyroid membranes. We have now studied 34 pure compounds identical or structurally related to compounds present in FDE from Lycopus or Lithospermum, 2 of the 3 species of active plants studied previously. In studies conducted at 4 C in 20 mM Tris-HCl-0.5% BSA buffer, pH 7.45, eight 3,4-dihydroxylated compounds, all structurally related to cinnamic acid, inhibited the binding of [125I] bTSH to human thyroid membranes. Of these, 4 (caffeic, rosmarinic, chlorogenic, and ellagic acids) are present in the plants, and 4 (3,4-dihydroxyphenylacetic acid, deoxyepinephrine, adenochrome, and nordihydroguaretic acid) are structurally related thereto. These compounds were inactive when tested directly but became active when allowed to undergo auto-oxidation. With all 8 compounds, half-maximum inhibition of [125I]bTSH binding required quantities of oxidized product equivalent to 20-80 micrograms/ml (60-195 microM) of the original compound. Half-maximum inhibitory concentrations of oxidized caffeic and ellagic acids were increased 2- to 4-fold when experiments were performed at 37 C in medium containing 50 mM NaCl. Preincubation of membranes with active oxidation products in concentrations up to 100 micrograms/ml, followed by washing, had no effect on the subsequent binding of [125I]bTSH. As has been shown in the case of FDE, when [125I]bTSH was preincubated with oxidation products of caffeic and ellagic acids and was then chromatographed on Sephadex G-100, its elution pattern was advanced from an apparent mol wt of 30,000 to the void volume, and [125I]bTSH in the early eluting fractions displayed greatly reduced binding to thyroid membrane preparations. Addition of a large excess of unlabeled bTSH during preincubation prevented the shift in the elution pattern of [125I]bTSH produced by these oxidation products. To ascertain whether FDE and active compounds interact with the protein or carbohydrate moieties of bTSH, studies of their effects on the binding and chromatographic behavior of 125I-deglycosylated-bTSH (dg-bTSH) were also performed. Effects were similar to those observed for intact bTSH, suggesting that they do not interact with the carbohydrate moiety of TSH. Preincubation of both bTSH and dg-bTSH with either active FDE or oxidation products of caffeic or rosmarinic acid also greatly decreased their activity in the McKenzie mouse assay.(ABSTRACT TRUNCATED AT 400 WORDS)     

Accuracy of in situ neck-shaft angle and shortening measurements of the anatomically reduced,varus malreduced and shortened proximal femur: Can we believe what we see on the postoperative films?

ObjectivesMeasuring the neck-shaft angle (NSA) and amount of shortening of the femoral neck on the anterior to posterior (AP) X-ray is important when treating proximal femur fractures. To compensate for proximal femoral external rotation, the X-rays need to be taken with the leg internally rotated, an act that cannot always be performed or verified. This study aims to define the utility of in situ AP X-ray in NSA and shortening measurements.MethodsComputed tomography (CT) scans of 50 patients undergoing abdominal CT scans were assessed for the in situ rotation of the femoral neck relative to the AP beam. Three proximal femur fracture Sawbones models were made and AP X-rays of the models were taken with changing proximal femur rotation. NSA and shortening were measured on all X-rays.ResultsIn situ femoral neck rotation averaged 25.4 ± 10.6° of external rotation (range, 0.9–51.8°, 80% of measurements less than 35°). NSA measurements varied less than 5° with less than 35° of rotation in all models, and were always greater than the true value. Femoral neck vertical length (VL) measurement was independent of proximal femur rotation whereas the horizontal length component was found to be highly dependent on the same.ConclusionsNSA measured on AP X-ray will be accurate to within 5° in 80% of patients with the hip left in situ and in 100% of the patients if the hip is internally rotated 15°. Measurement of significant varus or loss of VL of the femoral neck can be considered accurate regardless of leg rotation at the time of X-rays being taken.