Intra-abdominal surgery in patients with advanced cirrhosis

Between 1971 and 1984, intra-abdominal surgical procedures were required in 51 patients with cirrhosis who had advanced liver dysfunction and/or ascites. These included the following types of surgery: gastric, 17 patients; small bowel, two patients; colon, five patients; hepatic, nine patients; and pancreas, nine patients. Twelve patients also underwent exploratory celiotomy for an acute condition of the abdomen (six patients) and jaundice (six patients). Patients fell into two groups: (1) those with prothrombin time (PT) greater than 2.5 s over control (24 patients), and (2) those with PT within 2.5 s of control (27 patients). The 30-day mortality rate was 34 (67%) of 51 patients. Nineteen (83%) of 23 patients who had ascites died. Twenty-two (91%) of 24 patients with elevated PT greater than 2.5 s of control died. Twenty-five (86%) of 29 patients who underwent surgery under emergency conditions died. Intraabdominal surgery in decompensated patients with cirrhosis must be undertaken with great caution.     

The Role of Extended Lymphadenectomy for Adenocarcinoma of the Head of the Pancreas: Strength of the Evidence

With improvements in the safety of Whipple resection in recent decades, surgeons have continued to explore the role of more extensive lymphadenectomy in hope of improving long-term survival. A systematic literature search of level I evidence addressing the role of the extent of lymphadenectomy was undertaken. Only reports of prospective, randomized controlled trials comparing pancreaticoduodenectomy with standard lymphadenectomy to pancreaticoduodenectomy with extended lymphadenectomy where information regarding survival, morbidity, mortality, the number of resected lymph nodes in each group and detailed operative technique were included. Four prospective, randomized trials comprising some 424 patients and one meta-analysis were identified. In aggregate, these studies confirmed that the number of resected lymph nodes was significantly higher in the pancreaticoduodenectomy with extended lymphadenectomy group. Morbidity and mortality rates were comparable. Postoperative diarrhea in the early months after operation was problematic in patients undergoing extended lymphadenectomy. In none of the studies was a benefit in long-term survival demonstrated. Standard pancreaticoduodenectomy continues to be the operation of choice for adenocarcinoma of the head of the pancreas. Presented at The Society for Surgery of the Alimentary Tract Postgraduate Course “Systematic Reviews of Pancreaticobiliary Disease Customized for the Gastroenterologist and Gastrointestinal Surgeon” on May 20, 2007, Washington, D.C.     

Non-Hispanic Blacks undergoing distal pancreatectomy have higher risk-adjusted rates of morbidity and are more likely to be high-cost outliers

BackgroundFew studies evaluate racial disparities in costs and clinical outcomes for patients undergoing distal pancreatectomy (DP).MethodsWe queried the Healthcare Cost and Utilization Project State Inpatient Databases to identify patients undergoing DP. Multivariable regression (MVR) was used to evaluate the association between race and postoperative outcomes.Results2,493 patients underwent DP; 265 (10%) were black, and 221 (8%) were of Hispanic ethnicity. On MVR, black and Hispanic patients were less likely than whites to undergo surgery in high volume centers (OR 0.53, 95% CI [0.40, 0.71]; OR 0.45, 95% CI [0.32, 0.62]). Black patients had a greater risk of postoperative complication (OR 1.40, 95% CI [1.07, 1.83]), 90-day readmission (OR 1.53, 95% CI [1.15, 2.02]), prolonged length of stay (OR 1.74, 95% CI [1.25–2.44]), and of being a high cost outliers (OR 1.40, 95% CI [1.02, 1.91]) compared to white patients.ConclusionBlack patients have increased risk of having a postoperative complication, prolonged hospitalization, and of being a high-cost outlier than non-Hispanic whites.     

Successful nonoperative management of bleeding hepatic artery pseudoaneurysm following pancreaticoduodenectomy

BACKGROUND/AIMS: To report the management of a hepatic artery pseudoaneurysm presenting 35 days following a Whipple procedure. METHODS: The case study of a patient with a bleeding pseudoaneurysm is presented. RESULTS: Computed tomography demonstrated a pseudoaneurysm which was successfully embolized. CONCLUSIONS: Acute gastrointestinal bleeding from a pseudoaneurysm in the hepatic artery following Whipple procedure can be successfully managed with transcatheter embolization.     

How well do third-year medical students learn key objectives in a case-based surgical lecture series?

Faculty members were asked to list major and minor concepts of their case-based session presented during the 12-week 3rd-year surgical clerkship. After each session, students were queried to list the key concepts presented. Data were collected from two groups: one at the end of an academic year and a second at the beginning of the next academic year. Faculty members listed a median of 10 major and 15 minor concepts. The mean number of matched major concepts ranged from 0.2 to 4, and from 0.2 to 3.4 for minor concepts. In a comparative analysis, the end-of-the-year students listed a higher number of matched concepts for 17 of the 20 sessions than the beginning of the year students (8 sessions reached statistical significance, P < 0.05). The current case-based teaching method is not effective in emphasizing key concepts to students. Reformatting cases to better align with key concepts may be one solution to enhance a student's ability to grasp key concepts. Students at the end of the academic year outperformed those at the beginning of the year. This additional variable needs to be considered by faculty and incorporated into their teaching techniques.     

Effects of latex membrane on guided regeneration of long bones

Abstract

Natural latex extracted from Hevea brasiliensis is one of the materials pointed out as potential tissue regenerators. The use of latex-based membranes in bone regeneration might be an alternative to stimulate bone formation. The aim of this study was to evaluate the effects of latex membranes in guided bone regeneration of defects produced in long bones of rats. Sixty rats were equally divided into latex and control groups, and each group was subdivided into two subgroups according to treatment duration of 1 and 4 weeks. Bone defects with 2.5?mm in diameter were surgically made in the left tibia. In the animals of the latex group, a latex membrane was placed over the bone defect. The samples underwent quantitative histological analysis of bone formation and collagen matrix, immunohistochemical analysis of osteogenic protein markers, assessment of bone mechanical properties and bone densitometry, and radiological assessment. The osteocalcin immunostaining data were submitted to the generalized linear model test with two independent factors. For the other data, the multivariate ANOVA with two independent factors was performed. The use of the latex membrane significantly improved (p?<?0.005) the volume of newly formed bone, collagen type I matrix, expression of osteopontin, and bone stiffness, both in the early and late stages of regeneration. In conclusion, the latex membrane was able to promote bone regeneration in long bones.     

INSECTICIDE-TREATED BED NETS IN ROND?NIA,BRAZIL: EVALUATION OF THEIR IMPACT ON MALARIA CONTROL

Mosquito nets treated with long-lasting insecticide (LLINs), when used in compliance with guidelines of the World Health Organization, may be effective for malaria vector control. In 2012, approximately 150,000 LLINs were installed in nine municipalities in the state of Rondônia. However, no studies have assessed their impact on the reduction of malaria incidence. This study analyzed secondary data of malaria incidence, in order to assess the impact of LLINs on the annual parasite incidence (API). The results showed no statistically significant differences in API one year after LLIN installation when compared to municipalities without LLINs. The adoption of measures for malaria vector control should be associated with epidemiological studies and evaluations of their use and efficiency, with the aim of offering convincing advantages that justify their implementation and limit malaria infection in the Amazon Region.