Surgery News
Examination of the Impact of Airbags on Renal Injury Using a National Database
Little is known about preventative measures to lessen solid organ injury in motor vehicle collisions (MVCs). To evaluate the efficacy of airbags in reducing renal injuries in MVC, we analyzed renal injury rates in vehicles with and without airbags using the Crash Injury Research and Engineering Network (CIREN) database.
2,864 records were reviewed and identified 139 renal injuries (28.9% AAST grade III to V). In MVCs with renal injuries, frontal impact was 54.7% of total (n = 76) and side impact was 45.3% of total (n = 63). Most occupants in frontal impact MVCs had exposure to a steering wheel airbag (74.9%); 16.6% had an instrument panel (passenger) airbags. In side impact MVCs, 32.2% of occupants had a side airbag. Compared with the non-airbags cohort, frontal airbags and side airbags were associated with a 45.3% and 52.8% reduction in renal injury, respectively.
The use of laparoscopic surgery in pregnancy
Laparoscopic surgery in pregnant women has become increasingly more common since the 1990s; however, the safety of laparoscopy in this population has been widely debated, particularly in emergent and urgent situations. A retrospective chart review of all pregnant women following a nonobstetric abdominal operation at a University hospital between 1993 and 2007. Perioperative morbidity and mortality for the mother and fetus were evaluated. Cholecystectomy and appendectomy were performed in both groups with salpingectomy/ovarian cystectomy only in the laparoscopic group. No maternal deaths occurred, while fetal loss occurred in 3 cases within 7 days of the operation and in 1 case 7 weeks postoperatively. This and other perinatal complications occurred in 36.7% of the laparoscopic group and 41.7% of the open group. Overall, Laparoscopic appendectomy and cholecystectomy appear to be as safe as the respective open procedures in pregnant patients; however, this population in particular remains at risk for perinatal complications regardless of the method of abdominal access.
Surgical Decompression for Abdominal Compartment Syndrome in Severe Acute Pancreatitis
In patients with severe acute pancreatitis and abdominal compartment syndrome, establishment of the indications and optimal time for surgical decompression may avoid exacerbation of multiple-organ dysfunction syndrome. This was a retrospective review on twenty-six consecutive patients with severe acute pancreatitis and abdominal compartment syndrome treated by surgical decompression. At the time of surgical decompression, the median sequential organ failure assessment score among patients was 12, and the median intra-abdominal pressure was 31.5 mm Hg. After surgical decompression, renal or respiratory function was improved in 14 patients (54%). The overall hospital mortality was 46%, but mortality was 18% among 17 patients in whom surgical decompression was performed within the first 4 days after disease onset. Overall Surgical decompression may improve renal or respiratory function. Early surgical decompression is associated with reduced mortality in patients with severe acute pancreatitis, early multiple-organ dysfunction syndrome, and abdominal compartment syndrome.
FDA warns of migration and embolization with inferior vena cava filters, as new fracture data published
The Food and Drug Administration (FDA) has received more than 900 reports of adverse events with inferior vena cava (IVC) filters, leading the agency to remind clinicians that the devices should be removed as soon as it is safely possible [1]. The FDA's MedWatch warning comes as a new report on adverse events at a single center was published online August 9, 2010 in the Archives of Internal Medicine [2].
"The FDA is concerned that these retrievable IVC filters, intended for short-term placement, are not always removed once a patient's risk for pulmonary embolism [PE] subsides," according to the FDA's August 9, 2010 safety report. "Known long-term risks associated with IVC filters include but are not limited to lower limb deep vein thrombosis [DVT], filter fracture, filter migration, filter embolization, and IVC perforation."
Role of Prophylactic Antibiotics in Laparoscopic Cholecystectomy and Risk Factors for Surgical Site Infection: A Randomized Controlled Trial
The aim of this clinical trial was to determine whether prophylactic antibiotics could prevent surgical site infection (SSI) after laparoscopic cholecystectomy and to identify any risk factors for infection. The study included 100 patients undergoing laparoscopic cholecystectomy. They were randomized to receive either a single dose of ceftriaxone (Group A; n=50) or physiologic saline as placebo (Group B; n=50) after the induction of anesthesia. It was found that a single dose of prophylactic antibiotic failed to decrease the likelihood of SSI after laparoscopic cholecystectomy.
Just One Drop: The Significance of a Single Hypotensive Blood Pressure Reading During Trauma Resuscitations
Single, isolated hypotensive blood pressure (BP) measurements frequently are ignored or considered "erroneous." Although their clinical significance remains unknown,this article hypothesized that single, isolated hypotensive BP readings during trauma resuscitations signify the presence of severe injuries that often warrant immediate intervention. Cutpoint analysis determined that a single SBP reading <105 mm Hg best predicted the need for immediate therapeutic intervention. Although 38.1% patients with isolated SBP <105 mm Hg measurements underwent immediate therapeutic operative or endovascular procedures, only 10.4% (p < 0.001) with isolated SBP >=105 mm Hg required these procedures. Patients were 12.4 times more likely to undergo immediate therapeutic intervention than those with a single SBP >=105 mm Hg thus concluding that a single, isolated hypotensive BP measurements during trauma resuscitations should not be ignored or dismissed. Instead, our results suggest that a single SBP reading <105 mm Hg is associated with severe injuries that often require immediate operative or endovascular treatment and surgical intensive care unit admission.
Pyogenic liver abscesses: Diminished role for operative treatment
Pyogenic liver abscess is a rare but potentially serious condition. It has traditionally been treated by open drainage; however interventional radiology is now becoming the standard of care. All cases of liver abscesses admitted to a tertiary hospital over thirteen years (1995–2007) were retrospectively reviewed. Patient demographics, length of hospital stay, predisposing factors as well as cultured organisms were evaluated. Imaging techniques as well as patient management were also recorded. It was foundt that pyogenic liver abscesses are uncommon, and while associated with significant morbidity and prolonged hospital stay, mortality is now rare. Radiological intervention and anti-microbial therapy are the mainstay of treatment, and operative intervention is now rarely required.
Major haemorrhagic complications of acute pancreatitis
Haemorrhage is a rare, potentially fatal complication in acute pancreatitis (AP). The aim was to investigate the incidence, management and outcome related to this complication.
Fourteen (1·0 per cent) of 1356 patients diagnosed with AP developed major haemorrhage. Angiography established the diagnosis in four of six patients. Embolization was successful in one patient. Surgery was performed in two patients. Sentinel bleeding occurred in three of four patients with major postoperative bleeding. The overall mortality rate was 36 per cent (5 of 14 patients). Haemorrhage presenting after more than 7 days was associated with a higher mortality rate of 80 per cent (4 of 5 patients). A fatal outcome was at least three times more likely in patients with severe AP and haemorrhagic complications than in those with severe AP but no bleeding.Concluding major haemorrhagic complications of AP are rare, but clinically important. Major postoperative bleeding is often preceded by sentinel bleeding. Intra-abdominal haemorrhage presenting more than 1 week after disease onset is a highly fatal complication.
The value of pre-operative magnetic resonance cholangiopancreatography (MRCP) in management of patients with gall stones
This article analyzed the influence of pre-operative MRCP on the management of patients with gall stones through a prospective randomized study was carried on 250 patients who underwent laparoscopic cholecystectomy within 3 years. It found that MRCP is diagnostically useful in management of patients with gall stones prior to laparoscopic cholecystectomy and its routine use can reduce the incidence of post-operative complications.
Randomized comparison of Limberg flap versus modified primary closure for the treatment of pilonidal disease
The best surgical technique for sacrococcygeal pilonidal disease is still controversial. The aim of this randomized prospective trial was to compare both the results of Limberg flap procedure and primary closure.
Success of surgery was achieved in 84.62% of Limberg flap patients versus 77.69% of primary closure for which the surgical time for primary closure was shorter, also having a higher wound infection was more frequent in the primary closure group (P = .0254), but experienced less postoperative pain (P < .0001). Recurrence was observed in 3.84% versus 0% in the primary closure versus Limberg flap group. These results do not show a clear benefit for surgical management by Limberg flap or primary closure. Limberg flap showed less convalescence and wound infection; our technique of tension-free primary closure was a day case procedure, less painful, and shorter than Limberg flap.
Peripherally Inserted Central Catheters May Lower the Incidence of Catheter-Related Blood Stream Infections in Patients in Surgical Intensive Care Units
Long-term central venous catheterization is associated with a higher rate of catheter-related blood stream infections (CR-BSI). It is unclear whether there is a difference in the CR-BSI rate associated with central venous catheters (CVCs) and peripherally inserted central catheters (PICCs) in long-stay patients in surgical intensive care units (SICUs). This article hypothesized that PICC use reduces the rate of CR-BSI compared with use of antiseptic CVCs in these patients. In this non-randomized study, PICC was associated with fewer CR-BSIs in long-stay SICU patients, although CVCs were in place longer than PICC lines. The only predictor of CVC infection was the duration the line was in place. These results suggest that minimizing the duration of central venous access and substituting PICC for CVC may reduce the incidence of CR-BSI in long-stay SICU patients.
Computed tomographic colonography in the diagnosis of colorectal cancer
This study aimed to determine the sensitivity of computed tomographic colonography (CTC) in diagnosing colorectal cancer and to explore the reasons why these cancers are missed on CTC. Patients who underwent CTC in the 56-month period from 1 January 2004 to 1 September 2008, and all cases of colorectal cancer recorded in the National Cancer Registry database from 1 January 2004 to 1 December 2008, were identified. Overall the sensitivity of 95 per cent for CTC in the diagnosis of colorectal cancer compares favourably with that of double-contrast barium enema (92 per cent) and colonoscopy (94 per cent).
Routine Ultrasound and Limited Computed Tomography for the Diagnosis of Acute Appendicitis
Acute appendicitis continues to be a challenging diagnosis. Preoperative radiological imaging using ultrasound (US) or computed tomography (CT) has gained popularity as it may offer a more accurate diagnosis than classic clinical evaluation. The optimal implementation of these diagnostic modalities has yet to be established. The aim of the present study was to investigate a diagnostic pathway that uses routine US, limited CT, and clinical re-evaluation for patients with acute appendicitis. Positive and negative predictive values for the clinical diagnosis of appendicitis were 63 and 98%, respectively; for US 94 and 97%, respectively; and for CT 100 and 100%, respectively. The negative appendicitis rate was 3.3%, the perforation rate was 23.5%, and the missed perforated appendicitis rate was 3.4%. This study showed a diagnostic pathway using routine US, limited CT, and clinical re-evaluation for patients with acute abdominal pain can provide excellent results for the diagnosis and treatment of appendicitis.
Postoperative Calcium Requirements in 6,000 Patients Undergoing Outpatient Parathyroidectomy: Easily Avoiding Symptomatic Hypocalcemia
This study sought to determine the amount and duration of supplemental oral calcium for patients with varying clinical presentations discharged immediately after surgery for primary hyperparathyroidism. Overall there were seven parameters found to have a substantial impact on the amount of calcium required to prevent symptomatic hypocalcemia: preoperative serum calcium >12 mg/dL, >13 mg/dL, and >13.5 mg/dL, bone density T score less than −3, morbid obesity, removal of >1 parathyroid, and manipulation/biopsy of all remaining glands (all p < 0.05). Each independent variable increased the daily calcium required by 315 mg/day. Using our scaled protocol, <8% of patients showed symptoms of hypocalcemia, nearly all of whom were successfully self-treated with additional oral calcium. Only 6 patients (0.1%) required a visit to the emergency room for IV calcium, all occurring on postoperative day 3 or later.
Role of Prophylactic Antibiotics in Laparoscopic Cholecystectomy and Risk Factors for Surgical Site Infection
The aim of this clinical trial was to determine whether prophylactic antibiotics could prevent surgical site infection (SSI) after laparoscopic cholecystectomy and to identify any risk factors for infection. The study included 100 patients undergoing laparoscopic cholecystectomy. They were randomized to receive either a single dose of ceftriaxone or physiologic saline as placebo. It was shown that a single dose of prophylactic antibiotic failed to decrease the likelihood of SSI after laparoscopic cholecystectomy.
Tranexamic Acid Reduces Mortality in Trauma Patients
Tranexamic acid may be an effective option for reducing bleeding and mortality among trauma patients, without increasing the risk of serious complications such as myocardial infarction, stroke, or pulmonary embolism, according to a study published online June 15 in The Lancet.
Diagnosis of Necrotizing Soft Tissue Infections by Computed Tomography
In contrast to previous beliefs, an article in this weeks Archives of Surgery hypothesized that computed tomography (CT) scanning is sensitive and specific for the diagnosis of necrotizing soft tissue infections (NSTIs). Patients who were clinically suspected of having NSTIs from January 1, 2003, through April 30, 2009, and who underwent imaging with a 16- or 64-section helical CT scanner were studied. Of 67 patients with study inclusion criteria, 58 underwent surgical exploration, and NSTI was confirmed in 25 (43%). The remaining 42 patients had either nonnecrotizing infections during surgical exploration (n = 33) or were treated nonoperatively with successful resolution of the symptoms (n = 9). The sensitivity of CT to identify NSTI was 100%, specificity was 81%, positive predictive value was 76%, and negative predictive value was 100% concluding that a negative CT result reliably excludes the diagnosis of NSTI while a positive CT result correctly identifies the disease with a high likelihood.
Splenectomy leads to a persistent hypercoagulable state after trauma
It was hypothesized that splenectomy following trauma results in hypercoagulability. A prospective, nonrandomized, single-center study was performed to evaluate coagulation parameters in trauma patients with splenic injury. Overall it was found that fibrinogen was elevated, tissue plasminogen activator, plasminogen activator inhibitor–1, and activated partial thromboplastin time were higher in splenectomy patients and baseline thromboelastography showed faster fibrin cross-linking and enhanced fibrinolysis following splenectomy. The study also found that deep venous thrombosis developed in 7% of splenectomy patients and no control patients.
Screening for abdominal aortic aneurysms shows cost effectiveness
An article in this months British Journal of Surgery sought to estimate long-term mortality benefits and cost-effectiveness of screening for abdominal aortic aneurysm (AAA) in men aged 64-73 years. 6306 men were invited for abdominal ultrasonography at a regional hospital. Mortality and AAA-related interventions were recorded in national databases. The relative risk reduction of the screening programme in AAA-related mortality was 66 per cent (hazard ratio 0·34, 95 per cent confidence interval (c.i.) 0·20 to 0·57). The corresponding risk reduction in all-cause mortality was 2 per cent showing that there was a mortality benefit of screening for AAA in men aged 64-73 years that it was maintained in the longer term and screening was cost effective.
Failure to Perform Cholecystectomy for Acute Cholecystitis in Elderly Patients Is Associated with Increased Morbidity, Mortality, and Cost
Cholecystectomy during initial hospitalization is the current recommended therapy for acute cholecystitis. The rate of cholecystectomy and subsequent health care trajectory in elderly patients with acute cholecystitis has not been evaluated. An article in this months American College of Surgeons used 5% national Medicare sample claims data from 1996 to 2005 to identify a cohort of patients aged 66 years and older, requiring urgent or emergent admission for acute cholecystitis. The results of the study demonstrated that 25% of cholecystectomies on Medicare beneficiaries were not performed on initial hospitalization, leading to readmissions in 38% of surviving patients. For patients requiring readmission, the percentage of open procedures was increased, and the additional Medicare payment was $7,000 per re-admission. Cholecystectomy for acute cholecystitis in elderly patients should be performed during initial hospitalization to prevent recurrent episodes of cholecystitis, multiple readmissions, higher readmission rates, and increased costs.
Comparison of Laparoscopic and Open Repair With Mesh for the Treatment of Ventral Incisional Hernia
Laparoscopic repair of ventral incisional hernias has not been proved to be safer than open mesh repair. An article in this weeks Archives of Surgery published a prospective randomized trial that looked at one hundred sixty-two patients with ventral incisional hernias. Of the 162 randomized patients, 146 underwent surgery (73 open and 73 laparoscopic repairs). Surgical site infection through 8 weeks was less common in the laparoscopic group (5.6% vs 23.3%; AOR, 0.2; 95% CI, 0.1-0.6). The mean worst pain score in the laparoscopic group was 15.2 mm lower on a visual analog scale at 52 weeks (95% CI, 1.0-29.3; P = .04). Time to resume work activities was shorter for the laparoscopic group than for the open repair group (median, 23.0 days vs 28.5 days), with an adjusted hazard ratio of 0.54 (95% CI, 0.28-1.04; P = .06). Overall recurrence at 2 years was 12.5% in the laparoscopic group and 8.2% in the open repair group (AOR, 1.6; 95% CI, 0.5-4.7; adjusted P = .44).
