Systematic review of the safety and effectiveness of methods used to establish pneumoperitoneum in laparoscopic surgery

BACKGROUND

A systematic review was conducted to determine which of the methods of obtaining peritoneal access and establishing pneumoperitoneum is the safest and most effective.

METHODS

Studies that met the inclusion criteria were identified from six bibliographic databases up to May 2002, the internet, hand-searches and reference lists. They were critically appraised using a validated checklist and data were extracted using standardized protocols.

RESULTS

Meta-analysis of prospective, non-randomized studies of open versus closed (needle/trocar) access indicated a trend during open access towards a reduced risk of major complications (pooled relative risk (RR(p)) 0.30, 95 per cent confidence interval (c.i.) 0.09 to 1.03). Open access was also associated with a trend towards a reduced risk of access-site herniation (RR(p) 0.21, 95 per cent c.i. 0.04 to 1.03) and, in non-obese patients, a 57 per cent reduced risk of minor complications (RR(p) 0.43, 95 per cent c.i. 0.20 to 0.92) and a trend for fewer conversions to laparotomy (RR(p) 0.21, 95 per cent c.i. 0.04 to 1.17). Data on major complications in studies of direct trocar versus needle/trocar access were inconclusive. Minor complications in randomized controlled trials were fewer with direct trocar access (RR(p) 0.19, 95 per cent c.i. 0.09 to 0.40), predominantly owing to a reduction in extraperitoneal insufflation.

CONCLUSION

The evidence on the comparative safety and effectiveness of the different access methods was not definitive, but there were trends in the data that merit further exploration.

The screening pelvic radiograph in pediatric trauma

BACKGROUND

Pelvic radiographs are routinely obtained in adult trauma to optimise early management. In adults, pelvic fractures are associated with high early transfusion requirement, high injury severity scores and an increased incidence of other abdominal and thoracic injuries. It is unclear whether this holds true in children.

OBJECTIVE

To determine whether the screening pelvic radiograph is necessary in paediatric trauma.

MATERIALS AND METHODS

The notes of all patients who presented after trauma to the Starship Children's Hospital and were triaged to the resuscitation room during 1997 were reviewed. Results of initial radiography were obtained and correlated with later imaging.

RESULTS

Our review of 444 injured children seen over a period of 1 year revealed that of 347 children who had screening pelvic radiographs, only 1 had a pelvic fracture. The fracture in this child was clinically apparent and required no specific treatment.

CONCLUSIONS

The presence of a pelvic fracture is rare in injured children. By omitting screening pelvic radiographs there are potential benefits, including reduced radiation exposure to children and cost savings. Uninterpretable or abnormal clinical examination or haematuria requires further investigation, but routine screening for pelvic fracture is unnecessary.

Formation of 4-hydroxy-2-alkenals in barley leaves

In barley leaves 13-lipoxygenases are induced by jasmonates. This leads to induction of lipid peroxidation. Here we show by in vitro studies that these processes may further lead to autoxidative formation of (2E)-4-hydroxy-2-hexenal from (3Z)-hexenal.

Blunt traumatic small bowel rupture: are children different?

BACKGROUND

In order to identify differences between children and adults with small bowel rupture (SBR) and to determine if a single diagnostic approach could be taught to paediatric and adult surgeons, a review of the experience at a children's and an adults' hospital was performed.

METHODS

Using the hospital patient database 17 children were identified with SBR over a 13.6-year period, and clinical records were available for review for 14. Using a trauma registry 16 adults were identified with SBR over a 4.7-year period and clinical records were reviewed in all 16.

RESULTS

The population incidence was 0.48/100000 per annum in children and 0.58/100000 per annum in adults. Motor vehicle crash was a less common mechanism of injury in children (35.7%) than in adults (75%). The time from injury to presentation (presentation interval) was significantly longer in children than in adults, even after excluding child abuse cases (median 2.9 h vs 65 min, respectively). The injury severity score was lower in children (median: 10) than in adults (median: 16.5). Peritoneal signs on follow-up examination were documented in 54.6% of children and in 90.9% of adults in whom follow-up examination was performed. Clinical findings on admission, findings on computed tomography, indications for operation and outcome were similar in children and adults.

CONCLUSION

Children differed from adults in aetiology, longer presentation interval and fewer associated injuries. Similarities in diagnostic parameters suggest that a single diagnostic approach could be taught for children and adults provided that the limitations of physical examination in small children are recognized.

Oxygenation of (3Z)-alkenals to 4-hydroxy-(2E)-alkenals in plant extracts: a nonenzymatic process

There is large interest in 4-hydroxy-(2E)-alkenals because of their cytotoxicity in mammals. However, the biosynthetic pathway for these compounds has not been elucidated yet. In plants, 4-hydroxy-(2E)-alkenals were supposed to be derived by the subsequent actions of lipoxygenase and a peroxygenase on (3Z)-alkenals. The presence of 9-hydroxy-12-oxo-(10E)-dodecenoic acid (9-hydroxy-traumatin) in incubations of 12-oxo-(9Z)-dodecenoic acid (traumatin) in the absence of lipoxygenase or peroxygenase, has prompted us to reinvestigate its mode of formation. We show here that in vitro 9-hydroxy-traumatin, 4-hydroxy-(2E)-hexenal and 4-hydroxy-(2E)-nonenal, are formed in a nonenzymatic process. Furthermore, a novel product derived from traumatin was observed and identified as 11-hydroxy-12-oxo-(9Z)-dodecenoic acid. The results obtained here strongly suggest that the 4-hydroxy-(2E)-alkenals, observed in crude extracts of plants, are mainly due to autoxidation of (3Z)-hexenal, (3Z)-nonenal and traumatin. This may have implications for the in vivo existence and previously proposed physiological significance of these products in plants.

Thunderstorm-associated asthma in an inland town in south-eastern Australia. Who is at risk?

The aim of the study was to characterize patients at risk of asthma exacerbation during spring thunderstorms and identify potential measures to ameliorate the impact of those events. A case-control study was conducted among patients aged 7-60 yrs, who attended Wagga Hospital (NSW, Australia) for asthma during the period of 1 June 1997 to 31 October 1997. One hundred and eighty-three patients who attended on 30 and 31 October 1997 were the cases and the remaining 121 patients were the controls. Questionnaire data were obtained from 148 (81%) cases and 91 (75%) controls. One hundred and thirty-eight (95%) cases who attended during the thunderstorm gave a history of hayfever prior to the event compared to 66 (74%) controls who attended at other times (odds ratio (OR) 6.01, 95% confidence interval (CI) 2.55-14.15); 111 (96%) cases were allergic to rye grass pollen compared to 47 (64%) controls (OR 23.6, 95% CI 6.6-84.3). Among subjects with a prior diagnosis of asthma (64% cases and 82% controls), controls (56%) were more likely to be taking inhaled steroids at time of the thunderstorm than cases (27%, OR 0.3, 95% CI 0.16-0.57). History of hayfever and allergy to rye grass are strong predictors for asthma exacerbation during thunderstorms in spring. The lower rate of inhaled steroid use in thunderstorm cases suggests that this treatment may be effective in preventing severe attacks during thunderstorms.

Formation of lipoxygenase-pathway-derived aldehydes in barley leaves upon methyl jasmonate treatment

In barley leaves, the application of jasmonates leads to dramatic alterations of gene expression. Among the up-regulated gene products lipoxygenases occur abundantly. Here, at least four of them were identified as 13-lipoxygenases exhibiting acidic pH optima between pH 5.0 and 6.5. (13S,9Z,11E,15Z)-13-hydroxy-9,11,15-octadecatrienoic acid was found to be the main endogenous lipoxygenase-derived polyenoic fatty acid derivative indicating 13-lipoxygenase activity in vivo. Moreover, upon methyl jasmonate treatment > 78% of the fatty acid hydroperoxides are metabolized by hydroperoxide lyase activity resulting in the endogenous occurrence of volatile aldehydes. (2E)-4-Hydroxy-2-hexenal, hexanal and (3Z)- plus (2E)-hexenal were identified as 2,4-dinitro-phenylhydrazones using HPLC and identification was confirmed by GC/MS analysis. This is the first proof that (2E)-4-hydroxy-2-hexenal is formed in plants under physiological conditions. Quantification of (2E)-4-hydroxy-2-hexenal, hexanal and hexenals upon methyl jasmonate treatment of barley leaf segments revealed that hexenals were the major aldehydes peaking at 24 h after methyl jasmonate treatment. Their endogenous content increased from 1.6 nmol.g-1 fresh weight to 45 nmol.g-1 fresh weight in methyl-jasmonate-treated leaf segments, whereas (2E)-4-hydroxy-2-hexenal, peaking at 48 h of methyl jasmonate treatment increased from 9 to 15 nmol.g-1 fresh weight. Similar to the hexenals, hexanal reached its maximal amount 24 h after methyl jasmonate treatment, but increased from 0.6 to 3.0 nmol.g-1 fresh weight. In addition to the classical leaf aldehydes, (2E)-4-hydroxy-2-hexenal was detected, thereby raising the question of whether it functions in the degradation of chloroplast membrane constituents, which takes place after methyl jasmonate treatment.

The vulnerable stomach in babies born with pure oesophageal atresia

Nine babies with pure oesophageal atresia were treated in our institution in the years 1979-1996. All received a feeding gastrostomy as their initial operation. After initiation of gastrostomy feeds seven (78%) developed gastric complications, including two posterior gastric perforations (one fatal). We propose that the high complication rate is due to a small, abnormal stomach that is vulnerable to damage by operative trauma and the effects of handling large volumes of feed. We hypothesise that the stomach is abnormal because it has not been exposed to the maturing effects of amniotic fluid in utero. Feeds should be introduced very cautiously to these babies and built up very slowly.

Gonadal preservation in a simple testicular cyst

The authors report a case of a simple testicular cyst in a 16-week-old infant. Preoperative ultrasonography helped to diagnose this condition accurately. Gonadal preservation and enucleation of testicular cysts are possible with a careful surgical approach, and orchiectomy is not necessary.

Does gut atresia cause polyhydramnios?

Fetal gut atresia is variably associated with polyhydramnios. In order to determine which pregnancies will develop polyhydramnios, the case notes of 80 babies with gut atresia and stenosis were reviewed. Maternal polyhydramnios developed in all cases of pure oesophageal atresia (n = 8), all cases of Type III duodenal atresia (DA) with a non-bifid bile duct (n = 8), 80% of cases with type I DA (n = 10), and 24% of atresias of the small intestine (n = 34). Polyhydramnios did not develop in any case where there was not total obstruction except in 1 baby with DA and a bifid bile duct (BBD). These included stenosis of the oesophagus and duodenum (n = 17) and DA type III with a BBD (n = 3). These results support the role of fetal swallowing and fluid absorption by the fetal gastro-intestinal tract in the regulation of amniotic fluid volume.

Is a normally functioning gastrointestinal tract necessary for normal growth in late gestation?

It is known that neonates with congenital abnormalities of the intestine tend to be growth-retarded. We wished to explore the hypothesis that normal fetal gut function is needed for normal growth in late gestation. If this is true, then different populations of babies with different congenital gut abnormalities would be expected to have similar impairments of growth and be small at birth. This growth retardation would be more marked in term than in preterm babies and would be independent of other congenital anomalies. To test these hypotheses, we examined 43 babies born with gastroschisis (GS) in Auckland, New Zealand; 69 babies born with GS in Birmingham, England; and 60 babies born with intestinal atresia (IA) in Auckland. For Auckland babies with GS, the mean weight standard deviation score (WSDS) (i.e., birth weight relative to the mean birth weight for gestation) for term babies was lower than that for preterm babies (-0.932+/-0.180 vs -0.064+/-0.237, P=0.014). This was also true for Birmingham babies with GS (-0.991+/-0.193 vs -0.36 +/-0.153, P=0.028). For babies with IA, the mean WSDS for term babies was lower than that for preterm babies (-0.627+/-0.266 vs 0. 057+/-0.211, P=0.034). There was no significant difference between the mean WSDS of babies with and without major congenital abnormalities (-0.402+/-0.201 vs -0.271, P=0.70). Our results demonstrate that term babies born with GS are significantly growth-retarded compared with premature babies born with GS. Term babies born with a proximal IA are also growth-retarded. This strongly suggests that in late gestation, the normal growth is dependent on a normally functioning gastrointestinal tract that allows exposure of the proximal intestinal mucosa to ingested amniotic fluid.

Gastroschisis: can the morbidity be avoided?

Although the mortality associated with gastroschisis (GS) has fallen markedly over recent years, postoperative morbidity and the incidence of complications remain high. Many different factors may contribute to this morbidity; the aim of this study was to determine which factors contributed most. Measures of morbidity used were time to full oral feeding (FOF), time on parenteral nutrition (PN), age at discharge, and incidence of complications. Between 1969 and 1995, 44 neonates with GS were treated; there were 6 deaths. The average initial temperature of the patients who died was 34.6 degrees C compared with 36.0 degrees C for the rest of the group (P = 0.02). Staged repair and prematurity were associated with increased time to FOF, time on PN, and age at discharge (P < 0.001). When the corrected post-term age was used, the difference between preterm and term babies was no longer significant. Mode of delivery did not influence any measure of morbidity. Seventeen patients (46%) had complications related to PN administration and 18 (43%) developed complications related to their surgery. There were no significant differences in these measures of morbidity when comparing patients born in the first half of the study period with those born in the last half. Multivariate analysis revealed that time to FOF, time on PN, and age at discharge were all strongly independently associated with staged repair and with the presence of complications of PN (all F > 7.2 and P < 0.01). Mode of delivery, gestational age, admission temperature, the need for postoperative ventilation, and complications of surgery were not independently associated with any of the measures of morbidity examined. Our data suggest that term delivery and primary closure of the defect are likely to minimise the morbidity experienced by infants with GS.

Additional congenital anomalies in babies with gut atresia or stenosis: when to investigate, and which investigation

A wide variety of additional congenital anomalies occur in babies born with a gut atresia or stenosis. The specific pattern of anomalies depends on the location of the atresia. The serious nature of many of them makes perioperative diagnosis imperative. Eighty-six babies born with pure oesophageal atresia (OA), duodenal atresia (DA) or stenosis, or jejuno-ileal atresia (JIA) have been studied. These, combined with over 2,000 cases in the literature, have been used to develop a protocol to optimally investigate babies with gut atresia for associated anomalies. The authors recommend routinely obtaining anterio-posterior and lateral chest and abdominal radiographs for babies with pure OA, DA and intestinal atresia, making sure the entire spine can be visualised. Cardiac and renal ultrasonography (US) should be routine in all babies with pure OA or DA. A micturating cystourethrogram should be done in those babies with abnormal urinary tract US or an associated anorectal anomaly. A sweat test should be obtained in babies with JIA, and a rectal biopsy should be taken in babies with the combination of Down's syndrome and DA to exclude Hirschsprung's disease.

Paediatric renal trauma: caution with conservative management of major injuries

BACKGROUND

The kidney is the most frequently injured abdominal organ in children and controversy surrounds some aspects of management. This study looks at the experience of our institution and reviews the literature towards developing an optimal strategy for managing this common childhood injury.

METHODS

One hundred and forty-two cases of paediatric renal trauma are reported from a catchment population of approximately 240,000 children < 14 years of age over a 12 year period. Injuries were classified into four groups: groups 1 and 2 were regarded as minor injuries (85%) and group 3 and 4 injuries were those with extravasation of urine or pedicle injury (15%).

RESULTS

The male:female ratio was 2:1 with an average age of 8.5 years. Major renal injuries frequently required large amounts of resuscitation fluid. Associated injuries were present in 41% of all cases with an average of two injuries each. With one exception in each case, the development of complications and the need for early surgery were confined to major injuries. There were no long-term complications. The renal loss rate was 2.1%.

CONCLUSIONS

Renal injuries can be usefully classified into major or minor by determining whether extravasation of urine or pedicle injury is present. Minor injuries should be managed conservatively. Major injuries causing ongoing haemorrhage require urgent surgery. Other major injuries should be imaged regularly and patients with more severe urinomas benefit from early elective surgery at 2-5 days. In cases where extravasation of urine has not shown clear evidence of settling by 5 days' elective surgery probably results in less morbidity and fewer complications than protracted conservative treatment.

Recurrent sclerosing Basal-cell carcinomas requiring ablative cranio facial surgery - a 3-case report

The authors report on 3 cases of facial recurrent sclerosing basal cell carcinomas requiring large ablative cranio facial surgery and reconstruction involving regional or even free flaps. Special emphasis is made on the aggressive behavior of this specific histological form and on the necessity of an early diagnosis, a radical initial treatment and a close life time follow-up. Surgery with careful histological control of the margins is the treatment of choice whereas radiotherapy is an alternative for small lesions or nonsurgical patients. This early and aggressive therapeutic management is essential in order to avoid recurrences often requiring disfiguring surgery.

Does fibrin glue improve drainage after axillary lymph node dissection? Prospective and randomized study in humans

The aim of this prospective and randomized study was to establish whether the use of fibrin glue was beneficial after axillary lymph node dissection. From January 1990 to January 1991, 40 women were randomized before surgery for breast cancer: 20 patients (group A) underwent vaporization of fibrin glue (Tissucol, 5 ml of 500 IU thrombin) only in the area of axillary dissection; another 20 patients (group B) served as controls. The two groups were compared for age, number of nodes removed and involved, volume and duration of fluid drainage and complications. Student's t test, Mann-Whitney nonparametric test and the chi 2 test were used when appropriate for statistical analysis. The two groups were well balanced for age, number of nodes removed and involved, staging and histologic findings. The average volume of lymphorrhea in the lymph node dissection area was greater after use of fibrin glue (410.4 ml) than in controls (275.5 ml, p = 0.016). No difference was noted between the two groups for the volume of drainage fluid of the site of mastectomy or lumpectomy, or for the total volume of drainage fluid. Drainage duration as well as duration of hospital stay were similar. Six complications occurred in group A, and one in group B (p = 0.037).(ABSTRACT TRUNCATED AT 250 WORDS)

Hepatitis B vaccination of high-risk neonates in the South West Region of New South Wales: evaluation of program coverage

The authors evaluated the high-risk neonate hepatitis B vaccination program in the South West Region of New South Wales. Infants from ethnic groups with a high rate of chronic hepatitis B virus (HBV) infection and infants of HBV carrier mothers were targeted. The program identified 323 infants born between October 1987 and December 1990 who were at high risk of HBV infection, of whom 68.7 per cent were Aboriginal. Overall, 194 infants (60.1 per cent) received three doses of vaccine. Although the number of infants identified increased from 46 in 1988 to 119 in 1990, the proportion fully vaccinated each year did not increase, remaining at around 60 per cent. The authors stress the importance of promoting the program and educating the high-risk groups and health professionals involved, in order to improve vaccination coverage.

Non-traffic child pedestrian injuries

All non-traffic child pedestrian deaths and injuries resulting in hospitalization in the Auckland region over a 5 year period were identified from coroner's and hospital records. There were eight deaths (0.77/100,000 children per year) and 91 hospital admissions (8.7/100,000 children per year). Close to half (48%) of the non-traffic pedestrian injury admissions had been misclassified as traffic pedestrian injuries. Eighty-seven per cent of the non-traffic pedestrian injury deaths and 93% of the injuries occurred in residential driveways, most often involving a child run over by a reversing vehicle. Further studies are required to determine the most effective strategies for the prevention of non-traffic child pedestrian injuries.

Unpredictability of capsulotomy in testicular torsion

Testicular torsion results in irreversible histologic changes in the ipsilateral testis, which may induce alterations in contralateral testicular histology and in fertility. It was hypothesized that these ipsilateral changes could be minimized by splitting the tunica albuginea at the time of detorsion, thus decompressing the testicular "closed compartment syndrome." Unilateral spermatic cord torsion was induced in prepubertal, male Sprague Dawley rats for a period of 0, 4, 8, or 12 hours. At the time of detorsion, capsulotomy was performed on half the animals. The mature rats were killed 35 days after detorsion and the testes examined histologically. Testicular capsulotomy did not alter the significant histologic changes observed in the affected testis following spermatic cord torsion.

Ectopic calcitonin in adrenocortical carcinoma: a new tumor marker

Ectopic calcitonin has never before been described in association with pediatric malignancy. This is the first report of ectopic calcitonin in a child with adrenocortical carcinoma. It may prove to be a useful tumor marker in this, as well as other childhood malignancies.

Diagnosis of spontaneous perforation of the biliary tract in the newborn

This report is of a 2-month-old child with spontaneous perforation of the common bile duct diagnosed by 99m-Tc disofenin nuclear hepatobiliary imaging. Of the agents available, the radiopharmaceutical properties of this compound allow the most accurate, safe, high-resolution imaging of the hepatobiliary tree in the diagnostic evaluation of jaundiced infants.

[Metabolism of diphenylacetylglycine in higher plants]

Studies were conducted on the biotransformation of the growth-regulating diphenylacetylglycine. For this purpose this substance was radio-labelled prepared from (14COOH)diphenylacetic acid and glycine. In plants of wheat of the sort "Remo", barley of the sort "Certina", and tomatoes of the sort "Harzfeuer" the agent undergoes only a low metabolism. Diphenylacetic acid is not formed, therefore, the peptide linkages are rather stable. Only little quantities of more polar metabolites have been found, one of them being chromatographically indicated as diphenylacetylglycine glucose ester.