Does the complication rate increase in laparoscopic cholecystectomy for acute cholecystitis?

BACKGROUND: Laparoscopic cholecystectomy (LC) has replaced open cholecystectomy for the treatment of gallbladder disease. Despite the well-accepted success of LC in chronic cholecystitis, the efficacy of this technique has been subject to some debate in acute cholecystitis (AC). This study was designed to evaluate our institution's experience with LC for AC and chronic symptomatic calculous cholecystitis (CC), based on complication and conversion rates to open surgery. PATIENTS AND METHODS: The records of 1158 patients with LC from September 1991 to December 2001 were analyzed. The parameters of age, gender, early and late complication rates, and conversion rates from LC to open cholecystectomy were compared in patients with AC and CC. RESULTS: During the study period, LC was performed in 1158 patients. Of these, 162 patients had AC (group 1) and 996 patients had CC (group 2). The conversion rates were 4.3% (7/162) in group 1 and 2.4% (24/996) in group 2. The complication rates were not significantly different (5.6% in group 1, 5.1% in group 2, P > 0.05). Difficulty in dissection around Calot's triangle and obscure anatomy were the main reasons for conversion to conventional open surgery. The mortality rate was 1.2% in group 1 and 0.01% in group 2. CONCLUSION: LC appears to be a reliable, safe, and effective treatment modality for AC and CC. The surgical approach should be performed carefully because of the spectrum of potential hazards of the laparoscopic procedure. Conversion and complication rates are similar in both AC and CC groups, and improve as surgeons gain experience.     

Repetitively stretched tendon fibroblasts produce inflammatory mediators

We studied the expression of cytosolic phospholipase-A2 and activity of secretory phospholipase-A2 by human patellar tendon fibroblasts subjected to cyclic mechanical stretching. The effect of different stretching frequencies on the production of prostaglandin-E2 and expression of cyclooxygenase enzyme were also examined. An in vitro system that can control alignment, shape, and mechanical loading conditions of tendon fibroblasts was used for this study. Cyclic stretching of fibroblasts increased the expression level of cytosolic phospholipase-A2 by 88% and activity level of secretory phospholipase-A2 by 190%, compared with those of nonstretched fibroblasts. Cyclic stretching of tendon fibroblasts at 0.1 Hz and 1.0 Hz also increased prostaglandin-E2 production by 40% and 69%, respectively. Furthermore, cyclooxygenase-1 and cyclooxygenase-2 expression levels were increased in a stretching frequency-dependent manner, but cyclooxygenase-2 expression was increased more than that of cyclooxygenase-1. Because cytosolic phospholipase-A2 and secretory phospholipase-A2 are involved in the production of prostaglandin-E2 and other inflammatory mediators, this study suggests that regulation of phospholipase-A2 expression level may be an alternative approach to control in vivo tendon inflammation. The results of this study also may explain in part why activities that involve repetitive motion and high frequency loading of tendons are more likely to result in tendon inflammation.     

Effect of Acticoat® and Cutinova Hydro® on wound healing

In this study, the effects of the wound‐covering materials, Acticoat^® and Cutinova Hydro^®, on wound healing have been studied in rabbit models with open and tissue‐lost wounds with full‐thickness flank excisions. Rabbits were used as subjects with three groups of four rabbits each, and trial periods of 7, 14 and 21{\uns}days. Four circular wounds, of 1.5 cm diameter were made two on the right (one of them control) and two on the left (one of them control) of the dorsal sides of the abdomen. Acticoat^® and Cutinova Hydro^® were applied on the wounds with suture for a period of 21 days and one each placed on the right and left sides as control with gauze. Biopsy specimens were taken from the animals at the end of the research period to check the length of the epithelium, epithelial thickness, size of wounds, wound granulation tissue formation and histopathological evaluation for clarity. The Acticoat^® group showed better healing and scar formation compared to the Cutinova Hydro^® group by macroscopic examination. Epithelial wound length and clarity in terms of statistical difference occurred on day 21 (P <0.05); while the length of the wound epithelium decreased patency, epithelial thickness on days~7, 14 and 21, showed no statistical differences (P >0.05). As a result, the Acticoat^® wound dressing was determined as a more reliable for the early wound healing. This study has shown the short‐term clinical benefits of hydroactive, polyurethane dressings in the management of acute wounds. However, longer periods of wound healing procedure should be planned for reliable and safe results of wound dressing. It has also been concluded that microbiological analyses should be included for more robust and reliable comparisons.     

Management of Anemia in Children Receiving Chronic Peritoneal Dialysis

Little information exists regarding the efficacy, modifiers, and outcomes of anemia management in children with CKD or ESRD. We assessed practices, effectors, and outcomes of anemia management in 1394 pediatric patients undergoing peritoneal dialysis (PD) who were prospectively followed in 30 countries. We noted that 25% of patients had hemoglobin levels below target (<10 g/dl or <9.5 g/dl in children older or younger than 2 years, respectively), with significant regional variation; levels were highest in North America and Europe and lowest in Asia and Turkey. Low hemoglobin levels were associated with low urine output, low serum albumin, high parathyroid hormone, high ferritin, and the use of bioincompatible PD fluid. Erythropoiesis-stimulating agents (ESAs) were prescribed to 92% of patients, and neither the type of ESA nor the dosing interval appeared to affect efficacy. The weekly ESA dose inversely correlated with age when scaled to weight but did not correlate with age when normalized to body surface area. ESA sensitivity was positively associated with residual diuresis and serum albumin and inversely associated with serum parathyroid hormone and ferritin. The prevalence of hypertension and left ventricular hypertrophy increased with the degree of anemia. Patient survival was positively associated with achieved hemoglobin and serum albumin and was inversely associated with ESA dose. In conclusion, control of anemia in children receiving long-term PD varies by region. ESA requirements are independent of age when dose is scaled to body surface area, and ESA resistance is associated with inflammation, fluid retention, and hyperparathyroidism. Anemia and high ESA dose requirements independently predict mortality.Almost three decades after the advent of recombinant erythropoietin, the management of renal anemia has become a recent focus of attention and changing paradigms. Whereas correction of hemoglobin (Hb) levels to near-normal has previously been recommended on the basis of association studies linking more severe anemia to morbidity and mortality with dialysis,^1–3 interventional clinical trials consistently demonstrate that near-normalization of Hb increases the risk of vascular events and mortality in adults receiving maintenance hemodialysis and in those with CKD who are not undergoing dialysis.^4–6 This has prompted ongoing reevaluation and revisions of treatment targets in patients exposed to erythropoiesis-stimulating agents (ESAs).⁷The appropriateness of applying treatment recommendations established in adult hemodialysis populations at high cardiovascular risk and adults with CKD to children undergoing dialysis is questionable because cardiovascular events are far less common in children with CKD. Furthermore, two thirds of children requiring dialysis initially opt for peritoneal dialysis (PD), and there are no systematic studies in the adult PD population to inform the optimal Hb target range in these patients. The risk profile of patients receiving PD may differ from that of the hemodialysis setting because of the absence of dialysis-induced intermittent hemoconcentration and lack of contact activation of the complement and coagulation systems.Further aspects to consider in pediatric anemia management are the greater physical activity of children and the need for optimal cognitive functioning at school.^8,9 The significant physiologic variation of the normal Hb range with age¹⁰ and the relative ESA sensitivity that reportedly increases with age during early childhood are also noteworthy.¹¹The registry of the International Pediatric Peritoneal Dialysis Network (IPPN) prospectively collects detailed clinical, biochemical, dialysis, and medication-related information (including ESA types and doses and modalities of iron supplementation) from a substantial number of children undergoing long-term PD around the world. In-depth analysis of this unique database has allowed us to (1) gain insight into the demographic characteristics of renal anemia and its treatment in the pediatric PD population worldwide, (2) explore the relationship between ESA dose requirements and body dimensions, (3) identify factors contributing to ESA resistance in children, and (4) associate anemia control with patient outcomes.     

Evidence for a role of adaptive immune response in the disease pathogenesis of the MPTP mouse model of Parkinson's disease

Parkinson's disease (PD) is the second most common neurodegenerative disease and results from the loss of dopaminergic neurons of the nigrostriatal pathway. The pathogenesis of PD is poorly understood, but inflammatory processes have been implicated. Indeed increases in the number of major histocompatibility complex II (MHC II) reactive cells have long been recognised in the brains of PD patients at post‐mortem. However whether cells expressing MHC II play an active role in PD pathogenesis has not been delineated. This was addressed utilising a transgenic mouse null for MHC II and the parkinsonian toxin 1‐methyl‐4‐phenyl‐1,2,3,6‐tetrahydropyridine (MPTP). In wild‐type mice MHC II levels in the ventral midbrain were upregulated 1–2 days after MPTP treatment and MHC II was localized in both astrocytes and microglia. MHC II null mice showed significant reductions in MPTP‐induced dopaminergic neuron loss and a significantly reduced invasion of astrocytes and microglia in MHC II null mice receiving MPTP compared with controls. In addition, MHC II null mice failed to show increases in interferon‐γ or tumour necrosis factor‐α in the brain after MPTP treatment, as was found in wild‐type mice. However, interleukin‐1β was significantly increased in both wild‐type and MHC II null mice. These data indicate that in addition to microglial cell/myeloid cell activation MHC Class II‐mediated T cell activation is required for the full expression of pathology in this model of PD. GLIA 2016;64:386–395     

Inter- and intraobserver reliability of the Crowe and Hartofilakidis classifications in the assessment of developmental dysplasia of the hip in adult patients

Background

The purpose of this study is to investigate the inter- and intraobserver reliability of Crowe and Hartofilakidis classifications in the assessment of developmental dysplasia of the hip in adult patients.

Materials and methods

Two consultant orthopedic surgeons classified 141 dysplastic hips on 103 standard anterior–posterior pelvis radiographs according to the Crowe and Hartofilakidis classifications. Assessments were performed in random order by each observer on two separate occasions, at least 4?weeks apart. Kappa statistics were used to establish a relative level of agreement between observers for the two readings and between separate readings by the same observer.

Results

At the first readings, interobserver reliability analysis revealed kappa coefficient of 0.71 for the Crowe classification and 0.54 for the Hartofilakidis classification. At the second reading, the kappa coefficient was 0.72 for the Crowe classification and 0.75 for the Hartofilakidis classification. Intraobserver reliability analysis revealed kappa coefficients of 0.71 for the Crowe and 0.80 for the Hartofilakidis classification for observer A, and 0.76 and 0.70 for observer B.

Conclusions

In conclusion, we have found substantial inter- and intraobserver agreement for Crowe classification and substantial to moderate agreement for Hartofilakidis classification in this study. Both classification systems assess the different aspects of developmental dysplasia of hip in adults. Each system has advantages and disadvantages. We suggest using both of these classifications together to increase the accuracy.     

Conversion to Stoppa Procedure in Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair

Background and Objectives:

Conversion to open surgery is an important problem, especially during the learning curve of laparoscopic totally extraperitoneal (TEP) inguinal hernia repair.

Methods:

Here, we discuss conversion to the Stoppa procedure during laparoscopic TEP inguinal hernia repair. Outcomes of patients who underwent conversion to an open approach during laparoscopic TEP inguinal hernia repair between September 2004 and May 2010 were evaluated.

Results:

In total, 259 consecutive patients with 281 inguinal hernias underwent laparoscopic TEP inguinal hernia repair. Thirty-one hernia repairs (11%) were converted to open conventional surgical procedures. Twenty-eight of 31 laparoscopic TEP hernia repairs were converted to modified Stoppa procedures, because of technical difficulties. Three of these patients underwent Lichtenstein hernia repairs, because they had undergone previous surgeries.

Conclusion:

Stoppa is an easy and successful procedure used to solve problems during TEP hernia repair. The Lichtenstein procedure may be a suitable option in patients who have undergone previous operations, such as a radical prostatectomy.     

松质骨基质复合生物蛋白胶构建组织工程软骨的研究

目的尝试采用松质骨基质与生物蛋白胶复合材料构建组织工程软骨。方法体外培养大鼠软骨细胞,接种于松质骨基质／生物蛋白胶材料上行体外培养。采用HE、甲苯胺蓝染色免疫学检测、扫描电镜观察等方法观察所构建的组织工程软骨的特性。结果松质骨基质／生物蛋白胶组的组织学结构更接近于软骨样组织．其Ⅱ型胶原、蛋白多糖基因表达量及蛋白多糖含量明显高于松质骨基质组。结论松质骨基质／生物蛋白胶复合材料可用于构建组织工程软骨,是一种较理想的支架材料。     

Elective Noncardiac Surgery in Patients with Left Ventricular Assist Devices

Abstract As the number of heart failure patients supported with left ventricular assist devices (LVAD) increases, the frequency of elective, noncardiac surgery in this patient population will similarly rise. We retrospectively analyzed our LVAD patient database and identified six patients who underwent elective, noncardiac surgery while on LVAD support. These cases are discussed, with an emphasis on the anesthetic and perioperative considerations. These patients have an acceptable risk profile for elective surgery and should be treated similarly to their age‐matched counterparts not on LVAD support. (J Card Surg 2012;27:639‐642)     

Minimally Invasive Treatment of Pilonidal Disease: Crystallized Phenol and Laser Depilation

Pilonidal disease has been treated surgically and by various other methods for many years. The most important problem associated with such treatment is recurrence, but cosmetic outcome is another important issue that cannot be ignored. Today, crystallized phenol is recognized as a treatment option associated with good medical and cosmetic outcomes. We hypothesized that the addition of laser depilation to crystallized phenol treatment of pilonidal disease might increase the rate of success, and this study aimed to determine if the hypothesis was true. Patients who were treated with crystallized phenol and 755-nm alexandrite laser depilation were retrospectively analyzed. In total, 42 (31 male and 11 female) patients were treated with crystallized phenol and alexandrite laser depilation and were followed up between January 2009 and January 2012. In all, 38 patients (90.5%) had chronic disease and 4 (9.5%) had recurrent disease. Among the patients, 26 (61.9%) recovered following 1 crystallized phenol treatment, and the remaining patients had complete remission following repeated treatment. Some patients needed multiple treatments, even up to 8 times. None of the patients had a recurrence during a mean 24 months (range, 6–30 months) of follow-up. Whatever method of treatment is used for pilonidal disease, hair cleaning positively affects treatment outcome. The present results support the hypothesis that the addition of laser depilation (which provides more permanent and effective depilation than other methods) to crystallized phenol treatment (a non-radical, minimally invasive method associated with very good cosmetic results) can increase the effectiveness of the treatment and also reduce the recurrence rate of the disease.