Outcomes of asymptomatic common bile duct stones detected at intraoperative cholangiography

AIMS

The aim of this study was to investigate the outcome of common bile duct stones (CBDS) in asymptomatic patients at laparoscopic cholecystectomy (LC) and intra-operative cholangiogram (IOC).

METHODS

All patients undergoing LC and IOC at Te Whatu Ora - Health New Zealand Waikato between January 2017 and January 2022 were retrospectively reviewed. Electronic records were screened for asymptomatic CBDS. Exclusion criteria were hyperbilirubinaemia, gallstone pancreatitis, cholangitis and imaging-detected CBDS. IOC reports were reviewed to determine presence of CBDS. A second blinded review was undertaken by a radiologist. Outcomes were use of endoscopic retrograde pancreatography (ERCP), complications and readmission with retained CBDS.

RESULTS

Included were 1,297 patients undergoing LC and IOC. Of these, 150 (24.1%) patients had a positive IOC, of which 58 (38.7%) were asymptomatic. Attempted flushing of CBDS was employed in 49 cases, 10 successfully. Common duct exploration was successful in a further six out of seven cases. Of the remaining 42 patients, 18 were offered ERCP. Seven had no stone at endoscopy. Sixteen had imaging, revealing clear ducts in 14. The remaining two then had ERCP confirming choledocholithiasis. Eight patients were managed expectantly, of whom none required readmission with retained stones.

CONCLUSION

Rates of retained asymptomatic stones after positive IOC were low. Acknowledging risks associated with intervention and low rates of readmission with retained CBDS, an expectant approach could be more readily considered.

Association between frailty, long-term mortality and functional outcomes for older adults undergoing emergency laparotomy

BACKGROUND

An increasing number of older patients are undergoing emergency laparotomy (EL). Frailty is thought to contribute to adverse outcomes in this group. The best method to assess frailty and impacts on long-term mortality and other important functional outcomes for older EL patients have not been fully explored.

METHODS

A prospective multicenter study of older EL patients was conducted across four hospital sites in New Zealand from August 2017 to September 2022. The Clinical Frailty Scale (CFS) was used to measure frailty-defined as a CFS of ≥5. Primary outcomes were 30-day and one-year mortality. Secondary outcomes were postoperative morbidity, admission for rehabilitation, and increased care level on discharge. A multivariate logistic regression analysis was conducted, adjusting for age, sex, and ethnicity.

RESULTS

A total of 629 participants were included. Frailty prevalence was 14.6%. Frail participants demonstrated higher 30-day and 1-year mortality-20.7% and 39.1%. Following adjustment, frailty was directly associated with a significantly increased risk of short- and long-term mortality (30-day aRR 2.6, 95% CI 1.5, 4.3, p = <0.001, 1-year aRR 2.0, 95% CI 1.5, 2.8, p < 0.001). Frailty was correlated with a 2-fold increased risk of admission for rehabilitation and propensity of being discharged to an increased level of care, complications, and readmission within 30 days.

CONCLUSION

Frailty was associated with increased risk of postoperative mortality up to 1-year and other functional outcomes for older patients undergoing EL. Identification of frailty in older EL patients aids in patient-centered decision-making, which may lead to improvement in outcomes.

Rare finding of a symptomatic epidermoid cyst of the diaphragm - a case report

Cystic lesions of the diaphragm are rare and accordingly present a diagnostic challenge. Specific radiological features with which to clinch a diagnosis may be elusive. Herein we present the case of a patient who presented with symptoms attributable to a cyst in the left upper abdomen, irritating the diaphragm. Surgery was considered appropriate for diagnostic and symptomatic purposes. Final histology demonstrated an epidermoid cyst. Resolution of symptoms was reported after surgery. Diaphragmatic epidermoid cysts appear to be a rare entity with only three prior cases reported in the literature. Given the rarity of this lesion and the lack of unique features by which they can be characterized, accurately diagnosing epidermoid cysts of the diaphragm is likely to remain difficult without surgery, although they are presumed to have a benign behaviour.

Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries

BACKGROUND

Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide.

METHODS

This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters.

RESULTS

A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 per cent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 per cent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 per cent; however, it was 41 per cent in low-to-middle- compared with 19 per cent in very high-HDI countries.

CONCLUSION

Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761).

Novel application of Roux-en-Y for diversion of a cutaneous fistula from an irresectable mesenteric root mature teratoma: a case report

Reconfiguration of the alimentary tract with the Roux-en-Y has been utilized in a wide variety of contexts since its first description by Swiss physician César Roux. We present a novel and unique application of the Roux-en-Y whereby a chronically discharging cutaneous fistula originating at a retroperitoneal mature teratoma within the root of the mesentery was diverted enterically via a cystojejunostomy and the fistula tract excised, providing a resolution of symptoms. The location of the tumour in the root of the mesentery and the involvement of major mesenteric vessels made a radical resection of the tumour technically impossible but due to the distressing symptoms caused by the fistula made diversion of the fistula an excellent treatment option.

Weekend effect in emergency laparotomy: a propensity score-matched analysis

BACKGROUND

The 'weekend effect' is the term given to the observed discrepancy regarding patient care and outcomes on weekends compared to weekdays. This study aimed to determine whether the weekend effect exists within Aotearoa New Zealand (AoNZ) for patients undergoing emergency laparotomy (EL), given recent advances in management of EL patients.

METHODS

A cohort study was conducted across five hospitals, comparing the outcomes of weekend and weekday acute EL. A propensity-score matched analysis was used to remove potential confounding patient characteristics.

RESULTS

Of the 487 patients included, 132 received EL over the weekend. There was no statistically significant difference between patients undergoing EL over the weekend compared to weekdays. Mortality rates were comparable between the weekday and weekend cohorts (P = 0.464).

CONCLUSIONS

These results suggest that modern perioperative care practice in New Zealand obviates the 'weekend' effect.

Observation versus intervention for incidental common bile duct stones at intraoperative cholangiogram: a systematic review

BACKGROUND

The natural history of incidental common bile duct stones (CBDS) is poorly understood. Current evidence is conflicting, with several studies suggesting the majority may pass spontaneously. Despite this, guidelines recommend routine removal even if asymptomatic. This study aimed to systematically review the outcomes of expectant management for CBDS detected on operative cholangiography during cholecystectomy.

METHODS

MEDLINE, Embase and CINAHL databases were systematically searched. Participants were adult patients with CBDS identified by intraoperative cholangiography. Intervention was regarded as any perioperative effort to remove common bile duct stones, including endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic and open bile duct exploration. This was compared to observation. Outcomes of interest included rates of spontaneous stone passage, success of duct clearance and complications. Risk of bias was assessed using the ROBINS-I tool.

RESULTS

Eight studies were included. All studies were non-randomized, heterogeneous and at serious risk of bias. In patients observed after a positive IOC, 20.9% went on to have symptomatic retained stones. In patients directed to ERCP for positive IOC, persistent CBDS were found in 50.6%. Spontaneous passage was not associated with stone size. Meta-analysis is dominated by the results from one large database, which recommends intervention for incidental stones, despite low rates of persistent stones seen at postoperative ERCP.

CONCLUSIONS

Further evidence is required before a definitive recommendation on observation can be made. There is some evidence that asymptomatic stones may be safely observed. In clinical scenarios where the risks of biliary intervention are considered high, a conservative strategy could be more widely considered.

Variation in the practice of cholecystectomy for benign biliary disease in Aotearoa New Zealand: a population-based cohort study

INTRODUCTION

Cholecystectomy for benign biliary disease is common and its delivery should be standardised. However, the current practice of cholecystectomy in Aotearoa New Zealand is unknown.

METHODS

A prospective, national cohort study of consecutive patients having cholecystectomy for benign biliary disease was performed between August and October 2021 with 30-day follow-up, through STRATA, a student- and trainee-led collaborative.

RESULTS

Data were collected for 1171 patients from 16 centres. 651 (55.6%) had an acute operation at index admission, 304 (26.0%) had delayed cholecystectomy following a previous admission, and 216 (18.4%) had an elective operation with no preceding acute admissions. The median adjusted rate of index cholecystectomy (as a proportion of index and delayed cholecystectomy) was 71.9% (range 27.2%-87.3%). The median adjusted rate of elective cholecystectomy (as proportion of all cholecystectomies) was 20.8% (range 6.7%-35.4%). Variations across centres were significant (p < 0.001) and inadequately explained by patient, operative, or hospital-factors (index cholecystectomy model R² = 25.8, elective cholecystectomy model R² = 50.6).

CONCLUSIONS

Notable variation in the rates of index and elective cholecystectomy exists in Aotearoa New Zealand not attributable to patient, operative or hospital factors alone. National quality improvement efforts to standardise availability of cholecystectomy are needed.

Sensitization of colonic nociceptors by IL-13 is dependent on JAK and p38 MAPK activity

The effective management of visceral pain is a significant unmet clinical need for those affected by gastrointestinal diseases, such as inflammatory bowel disease (IBD). The rational design of novel analgesics requires a greater understanding of the mediators and mechanisms underpinning visceral pain. Interleukin-13 (IL-13) production by immune cells residing in the gut is elevated in IBD, and IL-13 appears to be important in the development of experimental colitis. Furthermore, receptors for IL-13 are expressed by neurons innervating the colon, though it is not known whether IL-13 plays any role in visceral nociception per se. To resolve this, we used Ca²⁺ imaging of cultured sensory neurons and ex vivo electrophysiological recording from the lumbar splanchnic nerve innervating the distal colon. Ca²⁺ imaging revealed the stimulation of small-diameter, capsaicin-sensitive sensory neurons by IL-13, indicating that IL-13 likely stimulates nociceptors. IL-13-evoked Ca²⁺ signals were attenuated by inhibition of Janus (JAK) and p38 kinases. In the lumbar splanchnic nerve, IL-13 did not elevate baseline firing, nor sensitize the response to capsaicin application, but did enhance the response to distention of the colon. In line with Ca²⁺ imaging experiments, IL-13-mediated sensitization of the afferent response to colon distention was blocked by inhibition of either JAK or p38 kinase signaling. Together, these data highlight a potential role for IL-13 in visceral nociception and implicate JAK and p38 kinases in pronociceptive signaling downstream of IL-13.

Conversion of locally advanced to resectable pancreatic body cancer aided by phosphorus-32 brachytherapy (OncoSil)

Nil.

Sensitisation of colonic nociceptors by TNFα is dependent on TNFR1 expression and p38 MAPK activity

Abstract

Visceral pain is a leading cause of morbidity in gastrointestinal diseases, which is exacerbated by the gut‐related side‐effects of many analgesics. New treatments are needed and further understanding of the mediators and mechanisms underpinning visceral nociception in disease states is required to facilitate this. The pro‐inflammatory cytokine TNFα is linked to pain in both patients with inflammatory bowel disease and irritable bowel syndrome, and has been shown to sensitize colonic sensory neurons. Somatic, TNFα‐triggered thermal and mechanical hypersensitivity is mediated by TRPV1 signalling and p38 MAPK activity respectively, downstream of TNFR1 receptor activation. We therefore hypothesized that TNFR1‐evoked p38 MAPK activity may also be responsible for TNFα sensitization of colonic afferent responses to the TRPV1 agonist capsaicin, and noxious distension of the bowel. Using Ca²⁺ imaging of dorsal root ganglion sensory neurons, we observed TNFα‐mediated increases in intracellular [Ca²⁺] and sensitization of capsaicin responses. The sensitizing effects of TNFα were dependent on TNFR1 expression and attenuated by p38 MAPK inhibition. Consistent with these findings, ex vivo colonic afferent fibre recordings demonstrated an enhanced response to noxious ramp distention of the bowel and bath application of capsaicin following TNFα pre‐treatment. Responses were reversed by p38 MAPK inhibition and absent in tissue from TNFR1 knockout mice. Our findings demonstrate a contribution of TNFR1, p38 MAPK and TRPV1 to TNFα‐induced sensitization of colonic afferents, highlighting the potential utility of these drug targets for the treatment of visceral pain in gastrointestinal disease.

Key points

The pro‐inflammatory cytokine TNFα is elevated in gastrointestinal disease and sensitizes colonic afferents via modulation of TRPA1 and Na_V1.8 activity. We further develop this understanding by demonstrating a role for p38 MAPK and TRPV1 in TNFα‐mediated colonic afferent sensitization. Specifically, we show that:

TNFα sensitizes sensory neurons and colonic afferents to the TRPV1 agonist capsaicin.

TNFα‐mediated sensitization of sensory neurons and colonic nociceptors is dependent on TNFR1 expression.

TNFα sensitization of sensory neurons and colonic afferents to capsaicin and noxious ramp distension is abolished by inhibition of p38 MAPK.

Collectively these data support the utility of targeting TNFα, TNFR1 and their downstream signalling via p38 MAPK for the treatment of visceral pain in gastrointestinal disease.

Beware the pancreatic incidentaloma in colorectal tumours: pancreatic adenocarcinoma with metastases to the colon and rectum

Colorectal cancer (CRC) is the third most diagnosed malignancy in the Western world. Routine staging of CRC often identifies incidental lesions on cross-sectional imaging. Appropriate treatment is dependent on a correct histological diagnosis. Pancreatic Ductal Adenocarcinoma (PDAC) is a rarer and often devastating diagnosis for which the treatment pathway differs significantly to CRC. We report two rare cases: the first recorded case of PDAC with synchronous rectal metastasis and a case of an acute presentation with large bowel obstruction from synchronous colonic metastasis. Both cases presented a significant diagnostic challenge. The management of both cases would have been altered had the histological diagnosis been known prior to surgery. Clinicians treating CRC should be wary of incidental lesions on staging investigations as they rarely represent an occult extra-intestinal primary malignancy. Immunohistochemistry plays an important role in ascertaining the origin of gastrointestinal malignancy.

Surgical management of duodenal web in an adult presenting with melaena; Case report and literature review

Introduction

Duodenal web is a rare pathology presenting infrequently in adults. Diagnosis is challenging and definitive management is commonly delayed. We present a case of a patient with a late diagnosis of duodenal web, who underwent laparotomy, intraoperative gastroscopy and surgical removal of the web performed by two general surgeons.

Case presentation

A 32-year-old woman with a previous diagnosis of irritable bowel syndrome presented with a three day history of abdominal pain, nausea and anorexia, and a one day history of melaena and haematemesis. Investigations including a magnetic resonance enterography, barium swallow study and gastroscopy revealed the diagnosis. The patient underwent laparotomy and excision of duodenal web. Intraoperative gastroscopy assisted with identification of the web's anatomical location. A longitudinal duodenotomy was performed and this was closed in a transverse fashion using the Heineke-Mikulicz technique.

Discussion

This case reports successful application of intraoperative gastroscopy during laparotomy and duodenotomy. Longitudinal duodenotomy with excision of the web and transverse closure of the duodenum appears to be the best approach. There are no previous publications detailing gastroscopy at the time of laparotomy with duodenal web. This technique may be utilised in appropriate situations to improve operative accuracy.

Conclusion

Duodenal web is a rare entity in adults, and delayed diagnosis may lead to significant patient morbidity. Incorporating intraoperative endoscopy ensures accurate anatomical visualisation. This technique avoids duodenectomy, organ damage, bypass, or an unnecessarily large incision.

•

Duodenal web is a rare diagnostic dilemma found infrequently in adults.

•

Duodenal web is frequently misdiagnosed and may not be visible on gastroscopy.

•

Investigations such as magnetic resonance enterography and barium swallow studies may be useful adjuncts for diagnosis.

•

Surgical management via laparotomy and duodenotomy are the best agreed cure for duodenal web.

•

Intraoperative gastroscopy is a novel technique that may improve patient outcomes by enhancing anatomical accuracy.

Noninvasive Mechanical Joint Loading as an Alternative Model for Osteoarthritic Pain

Objective

Mechanisms responsible for osteoarthritic (OA) pain remain poorly understood, and current analgesic therapies are often insufficient. This study was undertaken to characterize and pharmacologically test the pain phenotype of a noninvasive mechanical joint loading model of OA, thus providing an alternative murine model for OA pain.

Methods

The right knees of 12‐week‐old male C57BL/6 mice were loaded at 9N or 11N (40 cycles, 3 times per week for 2 weeks). Behavioral measurements of limb disuse and mechanical and thermal hypersensitivity were acquired before mechanical joint loading and monitored for 6 weeks postloading. The severity of articular cartilage lesions was determined postmortem with the Osteoarthritis Research Society International scoring system. To assess efficacy of various treatments for pain, 9N‐loaded mice were treated for 4 weeks with diclofenac (10 mg/kg), gabapentin (100 mg/kg), or anti–nerve growth factor (anti‐NGF) (3 mg/kg).

Results

Mechanical hypersensitivity and weight bearing worsened significantly in 9N‐loaded mice (n = 8) and 11N‐loaded mice (n = 8) 2 weeks postloading, compared to baseline values and nonloaded controls. Maximum OA scores of ipsilateral knees confirmed increased cartilage lesions in 9N‐loaded mice (mean ± SEM 2.8 ± 0.2; P < 0.001) and 11N‐loaded mice (5.3 ± 0.3; P < 0.001), compared to nonloaded controls (1.0 ± 0.0). Gabapentin and diclofenac restored pain behaviors to baseline values after 2 weeks of daily treatment, and gabapentin was more effective than diclofenac. A single injection of anti‐NGF alleviated nociception 2 days after treatment and remained effective for 2 weeks, with a second dose inducing stronger and more prolonged analgesia.

Conclusion

Our findings show that mechanical joint loading induces OA lesions in mice and a robust pain phenotype that can be reversed using analgesics known to alleviate OA pain in patients. This establishes the use of mechanical joint loading as an alternative model for the study of OA pain.

Communicating the location of potential skin neoplasms for excision between the referring and the operating doctor--an audit of skin lesion referrals in Whanganui, New Zealand

AIM

The importance of correctly defining the location of potential skin cancer when surgical treatment may be required is self-evident. Clear communication is essential if the professional diagnosing potential skin cancer is not the same professional providing treatment. We aimed to assess the nature of the localising information provided in referrals to the local anaesthetic skin lesion theatre in our institution.

METHODS

Information localising target lesions for new patients seen in our local anaesthetic skin excision theatre was recorded during a 2-month period April to May 2012 inclusive

RESULTS

100 patients were seen in our skin excision theatre during the study period; 16 patients were not able to identify the target skin lesion at the time they entered the operating theatre. The target lesion could not be determined from the referral text in 30/100 cases. Diagrams were provided in 19/100 cases. Photographs were provided in 3/100 cases.

CONCLUSIONS

Pictorial and photographic means of communicating the location of suspicious lesions are under-utilised in our service. Relying on the patient or the referral text to correctly identify the lesion leaves considerable room for error. We suggest that photographic information for skin lesion referrals is adopted as a minimum standard.

A two-center experience with the exclusive use of laparoscopic transperitoneal nephrectomy for benign renal disease in children

BACKGROUND

This study aimed to evaluate a two-center experience with pediatric transperitoneal laparoscopic nephrectomy, specifically focusing on the outcome parameters of operative time, complication, analgesic requirement, and postoperative stay.

METHODS

This ambispective study was conducted over a 4-year period between May 2001 and May 2005 in two tertiary pediatric surgical centers. Data were prospectively recorded from an in-house expanded medical audit system (EMAS) and a Microsoft Excel database. Information on patient demographics, operative time, complications, analgesic requirement, and length of hospital stay were retrieved and analyzed.

RESULTS

A total of 30 consecutive patients with a mean age of 4.43 years (range, 3 months to 15 years) underwent laparoscopic nephrectomy. All the patients underwent unilateral nephrectomy/nephroureterectomy for multidysplastic kidney (n = 12), reflux nephropathy (n = 13), pelvicoureteric junction obstruction (n = 4), or cystic disease of indeterminate cause (n = 1). The mean operative time was 93 +/- 30 min. The principal hemostatic devices used were the Harmonic Scalpel (20 cases), liga clips (5 cases), and hook diathermy and endoshears exclusively (4 cases). There were no conversions, but the intraoperative complications of bleeding (n = 2), difficult location (n = 1), difficult extraction (n = 1), and requirement for a liver retractor (n = 2) were encountered. An additional five patients had problems in the immediate postoperative period, two of whom went on to have long term difficulties with recurrent urinary tract infections resulting from a residual ureteric stump, which required surgery. Nearly one-third of the patients required morphine for analgesia in the immediate postoperative period, with the figure falling to 20% by day 1. The median postoperative hospital stay was 1 day (range, 0-16 days). At this writing, all the patients remain under surveillance with a mean follow-up period of 2.88 years, and no patients have experienced complications secondary to intraabdominal adhesions.

CONCLUSION

Transperitoneal laparoscopic nephrectomy is technically feasible in most cases of benign renal disease. The intraoperative complications are minimal, and recovery for most is robust. Two-thirds of the patients are discharged within 24 h. In this study, narcotic analgesics were prescribed in about a one-third of all the cases for a limited period. Further problems may be seen when refluxing ureters are incompletely excised. However, the transperitoneal approach does not mitigate against complete excision because the exposure to the pelvis is adequate. At the midterm follow-up assessment, adhesive obstruction was not encountered, confirming this approach as a tenable alternative to other laparoscopic approaches for nephrectomy.

AFM Study of Rubber Compounds

A series of rubber compounds filled with carbon blacks and silica has been studied by atomic force microscopy (AFM). The microdispersion of carbon black aggregates in rubber compounds can be clearly observed. The surface morphology of worn treads after road testing studied by AFM is also reported.

Lack of correlation between failure of gut barrier function and septic complications after major upper gastrointestinal surgery

OBJECTIVE

To determine the influence of abnormal gut barrier function on the risk of septic complications in patients undergoing major resectional surgery for upper gastrointestinal cancer.

SUMMARY BACKGROUND DATA

A failure of the gut mucosal barrier to exclude bacteria and endotoxin from the portal and systemic circulation is incriminated in the development of sepsis and multiple organ failure. Although the experimental data is compelling, corroborative evidence from studies in humans is sparse. This study attempted to correlate both preoperative gut barrier dysfunction and the pattern of change after surgery with septic outcome.

METHODS

Sixty-eight patients undergoing curative resectional surgery for upper gastrointestinal cancer were monitored for 30-day septic morbidity (intraabdominal abscesses/empyema and pneumonia). Intestinal permeability, serum IgM and IgG anti-endotoxin antibodies (EndoCAb), and serum C-reactive protein were measured before surgery and on postoperative days 1 and 7.

RESULTS

Increased intestinal permeability before surgery did not predict septic outcome. Major surgery was associated with increased intestinal permeability and evidence of endotoxin exposure. Comparing sepsis and nonsepsis groups, however, there was no significant difference in intestinal permeability, endotoxin exposure, and the acute phase response after surgery.

CONCLUSIONS

This study demonstrates that gut barrier dysfunction occurs after surgery, but the magnitude of change does not differentiate patients in whom sepsis develops and those in whom it does not. Preoperative increased intestinal permeability had no predictive value for sepsis. This study failed to support the thesis that gut barrier dysfunction is directly linked to sepsis.

Compared with parenteral nutrition, enteral feeding attenuates the acute phase response and improves disease severity in acute pancreatitis

BACKGROUND

In patients with major trauma and burns, total enteral nutrition (TEN) significantly decreases the acute phase response and incidence of septic complications when compared with total parenteral nutrition (TPN). Poor outcome in acute pancreatitis is associated with a high incidence of systemic inflammatory response syndrome (SIRS) and sepsis.

AIMS

To determine whether TEN can attenuate the acute phase response and improve clinical disease severity in patients with acute pancreatitis.

METHODS

Glasgow score, Apache II, computed tomography (CT) scan score, C reactive protein (CRP), serum IgM antiendotoxin antibodies (EndoCAb), and total antioxidant capacity (TAC) were determined on admission in 34 patients with acute pancreatitis. Patients were stratified according to disease severity and randomised to receive either TPN or TEN for seven days and then re-evaluated.

RESULTS

SIRS, sepsis, organ failure, and ITU stay, were globally improved in the enterally fed patients. The acute phase response and disease severity scores were significantly improved following enteral nutrition (CRP: 156 (117-222) to 84 (50-141), p < 0.005; APACHE II scores 8 (6-10) to 6 (4-8), p < 0.0001) without change in the CT scan scores. In parenterally fed patients these parameters did not change but there was an increase in EndoCAb antibody levels and a fall in TAC. Enterally fed patients showed no change in the level of EndoCAb antibodies and an increase in TAC.

CONCLUSION

TEN moderates the acute phase response, and improves disease severity and clinical outcome despite unchanged pancreatic injury on CT scan. Reduced systemic exposure to endotoxin and reduced oxidant stress also occurred in the TEN group. Enteral feeding modulates the inflammatory and sepsis response in acute pancreatitis and is clinically beneficial.

Energetic dysfunction in quinolinic acid-lesioned rat striatum

Impairment of mitochondrial energy metabolism may contribute to the selective neuronal degeneration observed in Huntington's disease and other neurodegenerative disorders. Intrastriatal injection of the excitotoxin, quinolinic acid, produces a pattern of neuronal death similar to that seen in Huntington's disease. However, little is known about the effects of quinolinic acid on striatal energetics. In the present work, time-dependent changes in energy metabolism caused by injection of quinolinic acid into rat striatum were examined. Oxygen consumption by free and synaptic mitochondria was quantified and correlated with the concentrations of nucleotides and amino acids at different times after injection. Compared with saline-treated controls, a decrease in ADP-stimulated (state 3) to basal (state 4) oxygen consumption (respiratory control ratio) by free mitochondria was apparent in quinolinic acid-injected striata as early as 6 h after treatment. No significant changes were seen in nucleotide concentrations at this time. By 12 h after injection, the decline in the respiratory control ratio was more pronounced (45%), and reductions in ATP, NAD, aspartate, and glutamate (30-60%) were also observed. These results show that injection of quinolinic acid in vivo produces progressive mitochondrial dysfunction, which may be a common and critical event in the cell death cascade initiated in Huntington's disease and in animal models of this neurodegenerative disorder. The indicators of mitochondrial function examined in this study, therefore, may be useful in evaluating the efficacy of neuroprotective agents.

Informatics: a physician's view

From bedside to boardroom, physicians are coming on-line to use automated information systems. Physicians are increasingly able to scroll through computer screens to scan images and lab summaries. But they will obtain their most critical data by listening to, observing, and examining patients. Practitioners will be driven in two diagnostic realms by informatics: acute care and chronic care. Training of both internists and surgeons will be enhanced. Nurses will be able to take on more of doctors' work. Telemedicine may eventually reduce patient visits to the office and doctors' trips to the emergency department. Health care system management is strengthened and network message traffic smoothed by informatics, but lack of trust will slow acceptance.

Self-regulation: the true key to success of physician-directed networks

The purpose of regulation is to promote uniformly high quality health care at a reasonable cost. The purpose of self-regulation is to make regulation more acceptable to the network physicians and create an atmosphere of continual improvement in bedside care. Interviews with medical directors of group practices, independent physician associations, managed care plans, national specialty networks, and physician-hospital organizations were used to learn what methods of self-regulation are popular and effective.

Accounting for the transition from inpatient to outpatient surgery

This article reports on some of the factors that have advanced and impeded hospital progress in moving from inpatient to outpatient surgery. Early on, patients, physicians, and hospital administrators all agreed that outpatient surgery had an intuitive appeal. Patients liked it because they didn't have to go in the hospital. Physicians liked it because they could get in and out of the outpatient surgery center more easily than the main hospital operating room. Administrators recognized the inherent appeal of outpatient procedures but were unable or unwilling to switch services from inpatient to outpatient for a variety of reasons. First, empty hospital beds and diminished scope of inpatient operations are a threat to the power of administrators. Moving surgery from inpatient to outpatient settings reduces inhouse operations. Second, reimbursement incentives were definitely in favor of continued inpatient care long after technology was in place for outpatient care. The third and most critical reason was that cost data on outpatient operations were just not available for making decisions on when to move into the outpatient setting. This review of the literature was intended to document the lack of relevant cost-based accounting. Instead, many other factors that more directly slowed progress were encountered. More than anything, this illustrates the erratic course of progress in health care reform.

Cost containment in emergency departments

Traditionally, cost effectiveness has been overlooked in emergency departments because of a mandate to provide emergency care in every community regardless of expense. However, in the current era of managed care, reduced reimbursement, and cost controls, emergency departments are being examined more carefully to determine whether their costs can be contained or even whether they can become profit centers. Detailed billing, cost accounting, enhanced communication among emergency departments within a community, and linking of suburban and inner-city emergency departments are several means by which emergency departments can control costs and raise revenues.

Blood flow and metabolism in vasogenic oedema

The relationship between white matter cerebral blood flow (CBF) and glucose metabolism (LCMRgl) was studied in a plasma infusion model of vasogenic oedema in cats. LCBF as determined by iodoantipyrine was found to be significantly decreased in oedematous white matter (17.3 +/- 1.5 ml/100 gm/min) when compared with contralateral control white matter (24.8 +/- 1.8 ml/100 gm/min). If the values for oedematous brain were corrected for dilution, however, the LCBF averaged 25.3 +/- 1.7 ml/100 gm/min, which was the same as control. LCMRgl was found to be significantly increased in plasma-infused white matter (16.3 +/- 2.2 mumol/100 gm/min), compared with control white matter (10.7 +/- 1.3). This difference remained despite correction for dilution and recalculation of LCMRgl values based on altered kinetic constants found in oedematous brain. A similar increase in LCMRgl was noted with saline infusion oedema. It is concluded that increased tissue water does not alter CBF, but does induce an increase in anaerobic metabolism.

Cerebral blood flow and glucose metabolism in experimental brain edema

The relationship between cerebral blood flow (CBF) and cerebral metabolic rate of glucose (CMRgl) in the white matter was studied in a plasma infusion model of vasogenic edema in cats. Local CBF, as determined by iodoantipyrine testing, was found to be significantly decreased in edematous white matter (mean +/- standard error of the mean: 17.3 +/- 1.5 ml/100 gm/min) when compared with CBF in the contralateral control white matter (24.8 +/- 1.8 ml/100 gm/min). When the values for edematous brain were corrected for dilution, however, the local CBF averaged 25.3 +/- 1.7 ml/100 gm/min, which was similar to the control value. Local CMRgl was found to be significantly increased in plasma-infused white matter (16.3 +/- 2.2 mumol/100 gm/min) compared with that in control white matter (10.7 +/- 1.3 mumol/100 gm/min). This difference remained, despite correction for dilution and recalculation of local CMRgl values based on altered kinetic constants found in edematous brain. A similar increase in local CMRgl was noted with saline-infusion edema. It is concluded that the increased tissue water level does not alter CBF, but does induce an increase in anaerobic metabolism.

A microtiter plate technique for the detection of platelet antibodies and platelet antigen typing

A microtiter plate assay is described for platelet serologic studies. The assay is based on an indirect radiolabeled antiglobulin test. The test was performed in microtiter wells of 400 microliter capacity manufactured to form strips that fit into a standard 96-well carrier. The strips were broken apart and placed into tubes for counting in a gamma counter. The technique does not require fixation of the platelets to the wells. Freshly collected platelets or platelets that have been stored frozen in 5 percent dimethylsulfoxide can be used. Results are presented using the technique for platelet alloantibody identification, platelet antigen typing, and platelet crossmatching.

Otoplasty: Excision of conchal floor cartilage

In 10 consecutive otoplasties, conchal floor cartilage was excised to facilitate rotating prominent ears back against the head. The procedure is most effective in aural prominence due to deep conchae. Cosmetic improvement is as good as that achieved by excision of posterior wall cartilage, and recontouring of the antihelix fold is needed less often. The amount of cartilage to remove is easily determined, matching of asymmetrically prominent ears is simplified, and concha-mastoid sutures can be placed without tension. The corrections have been followed 1-2 years without recurrence of the deformity.

Bioenergetics of acute vasogenic edema

The bioenergetic mechanisms of vasogenic edema were studied by measuring concentrations of adenosine triphosphate (ATP), phosphocreatine (CrP), and lactate in rapidly frozen edematous white matter in cats. When edema was produced using a cold lesion, it was found that both ATP and CrP were reduced to one-half of control values, and that lactate was elevated. When a correction was applied for dilution, however, it was found that high-energy phosphates were equal to control values, and that lactate was even more significantly elevated. This pattern contrasted with that seen in white-matter ischemia, in which CrP is depressed out of proportion to ATP. Finally, it was found that the white-matter lactate-concentration in the plasma infusion model of edema was increased. It is concluded that vasogenic edema induces an increase in lactate, but does not deplete high-energy phosphate compounds in affected white matter.

The effects of cold-induced brain edema and white-matter ischemia on the somatosensory evoked response

The electrophysiological effects of cold-lesion edema and white-matter ischemia were studied in cats by reference to the short-latency somatosensory evoked response. The primary cortical waves were found to be considerably delayed following a period of white-matter ischemia; hosever, cold-lesion edema appeared to have no significant effect on the evoked response. The authors conclude that vasogenic edema does not interfere with axonal functioning by an ischemic mechanism.

Versatility of lumbar transposition flaps in the closure of meningomyelocele skin defects

A simple method for repair of skin defects after neurosurgical ablation of meningomyelocele is described. One or two skin flaps adjoining the defect are elevated, the right based superiorly and the left inferiorly. They are then transposed to cover the dural repair, and the donor site is repaired by a split-thickness skin graft. The ability of these flaps to close defects of all sizes is stressed.

Cytotoxic edema produced by 6-aminonicotinamide and its response to therapy

Cytotoxic brain edema was produced in rabbits with intraperitoneal administration of a metabolic inhibitor, 6-aminonicotinamide. Paraplegia, diminished feeding, globally diminished muscle tone, and poor coordination were evident 48 hours after the initial administration of the drug and the electroencephalogram (EEG) was characterized by pronounced slowing and diminished voltage. Cisternal monitoring of intracranial pressure (at a pACO2 of 38 to 42 torr) revealed that it was significantly higher than in controls (p &lt; 0.001). Measurements of phosphocreatine, lactate, and NADH did not differ from control values, but total nicotinamide adenine dinucleotide (NAD+/NADH) showed a significant decrease in the experimental group (p &lt; 0.001). Water content of the gray matter was significantly higher in the experimental group when compared to that in controls (p &lt; 0.001). Mannitol and furosemide produced a significant reduction in intracranial pressure (ICP) (p &lt; 0.001) and lowered the water content of the gray matter (p &lt; 0.001). Both agents improved the slow wave form of the EEG 20 minutes after their administration intravenously in 50% of the animals. Dexamethasone (1 mg/kg) was administered with 6-aminonicotinamide 2 days before the experimental day. In 50% of this group, the behavior and EEG were similar to those of normal rabbits, and on the experimental day ICP was slightly lower than that in untreated animals (p &lt; 0.01). The decrease in water content of the gray matter in the steroid group was significantly less than that produced by mannitol and furosemide.

Meningomyelocele skin defects

Meningomyelocele skin defects in ten newborn infants were closed with bilateral lumbar transposition flaps and split-thickness skin grafts. Eight repairs healed promptly without incident. The superficial layer of the flaps in one patient necrosed and were replaced by skin grafts. One patient died of pneumonia and overwhelming sepsis, though the flaps and grafts were healing without reaction. These flaps were useful, even when small, because their placement could be varied to completely cover the defect.