Air Leak Test Research Articles

Rate of Organ Space Infection Is Reduced with the Use of an Air Leak Test During Major Hepatectomies

BackgroundOrgan/space surgical site infections (OSIs) constitute an important postoperative metric. We sought to assess the impact of a previously described air leak test (ALT) on the incidence of OSI following major hepatectomies. MethodsA single-institution hepatobiliary database was queried for patients who underwent a major hepatectomy without biliary-enteric anastomosis between January 2009 and June 2015. Demographic, clinicopathologic, and intraoperative data—including application of ALT—were analyzed for associations with postoperative outcomes, including OSI, hospital length of stay (LOS), morbidity and mortality rates, and readmission rates. ResultsThree hundred eighteen patients were identified who met inclusion criteria, of whom 210 had an ALT. ALT and non-ALT patients did not differ in most disease and treatment characteristics, except for higher rates of trisegmentectomy among ALT patients (53 vs. 34 %, p = 0.002). ALT patients experienced lower rates of OSI and 90-day morbidity than non-ALT patients (5.2 vs. 13.0 %, p = 0.015 and 24.8 vs. 40.7 %, p = 0.003, respectively). In turn, OSI was the strongest independent predictor of longer LOS (OR = 4.89; 95 % CI, 2.80–6.97) and higher rates of 30- (OR = 32.0; 95 % CI, 10.9–93.8) and 45-day readmissions (OR = 29.4; 95 % CI, 10.2–84.6). ConclusionsThe use of an intraoperative ALT significantly reduces the rate of OSI following major hepatectomy and may contribute to lower post-discharge readmission rates.

Water-Soluble Enema Prior to Ileostomy Closure in Patients Undergoing Low Anterior Resection: Is It Necessary?

BackgroundDiverting ileostomy is recommended in patients undergoing neoadjuvant chemoradiotherapy and low anterior resection for low-rectal cancer. Prior to ileostomy reversal, water-soluble enema is performed to assess the low colorectal anastomosis. The aim of this study was to assess whether performance of routine water-soluble enema prior to ileostomy takedown is necessary. Materials and MethodsAll mid-low rectal cancer patients who underwent low anterior resection with temporary diverting ileostomy after neoadjuvant chemoradiotherapy, between 2006 and 2013, were identified, retrospectively. The colorectal anastomosis prior to ileostomy takedown was evaluated by digital rectal exam, rigid proctoscopy, and water-soluble enema. The rectal exam and proctoscopy findings were compared to those of the water-soluble enema. The efficacy of routine water-soluble enema was assessed. ResultsThree hundred and twelve (184 male) patients (mean age 62.2 ± 17 years) met the inclusion criteria. Ten patients (3 %) experienced a contained anastomotic leak in the early postoperative period, of whom six had a positive intraoperative air leak test at the index operation. At follow-up, 12 patients (4 %) presented with anastomotic stricture, which was diagnosed by rectal exam and proctoscopy. In 11 of them, water-soluble enema showed anastomotic stricture. In terms of anastomotic defects, sinus was documented in two patients (0.6 %), yet digital rectal exam and proctoscopy were normal. No late septic complications related to the colorectal anastomosis after ileostomy closure were reported. The sensitivity of rectal exam, and proctoscopy for the diagnosis of anastomotic stricture was 100 %, while its negative predictive value for the diagnosis of anastomotic defect was 99 %. ConclusionRoutine water-soluble enema for the evaluation of colorectal anastomosis before ileostomy takedown does not provide additional information that changes patient management. The efficacy of this test in patients after neoadjuvant chemoradiotherapy and low anterior resection should be reassessed.

Is the intraoperative air leak test effective in the prevention of colorectal anastomotic leakage? A systematic review and meta-analysis.

ObjectiveThe intra-operative air leak test (ALT) is a common intraoperative test used to identify mechanically insufficient anastomosis. This meta-analysis aims to determine whether ALT aids to the reduction of postoperative colorectal anastomotic leakage (CAL).MethodsA literature search was performed to select studies in acknowledged databases. Full text articles targeting ALT during colorectal surgery were included. Quality assessment, risk of bias, and the level-of-evidence of the inclusions were evaluated. ALT methodology, ALT(+) (i.e., leak observed during the test) rate, and postoperative CAL rate of the included studies were subsequently analyzed.ResultsTwenty studies were included for analysis, in which we found substantial risks of bias. A lower CAL rate was observed in patients who underwent ALT than those did not; however, the difference was not significant (p = 0.15). The intraoperative ALT(+) rate greatly varied among the included studies from 1.5 to 24.7 %. ALT(+) patients possessed a significantly higher CAL rate than the ALT(−) patients (11.4 vs. 4.2 %, p < 0.001).ConclusionsBased on the available evidence, performing an ALT with the reported methodology has not significantly reduced the clinical CAL rate but remains necessary due to a higher risk of CAL in ALT(+) cases. Unfortunately, additional repairs under current methods may not effectively decrease this risk. Results of this review urge a standardization of ALT methodology and effective methods to repair ALT(+) anastomoses.

A FIELD STUDY SETUP OF FOUR HOMES HAVING NON-VENTILATED AND SEMI-CONDITIONED SEALED ATTICS

INTRODUCTION The University of Florida (UF) and the Oak Ridge National Laboratory (ORNL) are evaluating the hygrothermal (heat and moisture flow) performance and durability of sealed attic construction where open cell spray polyurethane foam (ocSPF) insulation is applied directly to the underside of the roof deck. During the 2015–2016 fiscal year and with financial support from the Florida Building Commission (FBC) and the Florida Roofing and Sheet Metal Contractors Association (FRSA), UF and the ORNL Building Technology Research Integration Center (BTRIC) completed Phase I of a study that setup four residential home demonstrations in Florida climate zones CZ-1A and CZ-2A. Field measurements for the homes are listed in Table 1. The four homes are instrumented for measuring temperature and relative humidity of the indoor living space, the outdoor air and the attic air. In addition, the temperature, relative humidity and moisture content of the roof sheathing are being monitored and recorded by remotely-accessible data acquisition equipment. Air leakage tests on the whole house, on the sealed attic and in the HVAC ducts were conducted on all four homes, Table 1. Digital and infrared images were captured to document the thermal performance of the sealed attics. Field tests commenced on June 1, 2016. Data acquisition will continue for one full year to document heat and moisture flows, which, in turn will be used in a second phase of work to benchmark an analytical tool kit for predicting the heat and moisture flows in Florida's hot and humid climate. The second phase of work is pending approval by the FBC.

413 Rate of Organ Space Infection Is Reduced With the Use of an Air Leak Test During Major Hepatectomies

413 Rate of Organ Space Infection Is Reduced With the Use of an Air Leak Test During Major Hepatectomies

Intensive care management of children intubated for croup: a retrospective analysis.

Croup remains the commonest reason for acute upper airway obstruction in children, yet there are scarce contemporary data of airway management in those requiring intubation. We performed a retrospective analysis of the intensive care management of children intubated for croup in two quaternary Paediatric Intensive Care Units: Royal Children's Hospital Melbourne, Australia and Alberta Children's Hospital Calgary, Canada. Patients intubated for less than three days were compared with those intubated for greater than three days. Patients less than 10 kg body weight were compared to those greater than 10 kg. Demographic, clinical and microbiological data were recorded. Seventy-seven cases of croup requiring intubation were identified. The median duration of intubation was 60 hours. Parainfluenza was the most common viral aetiology, detected in 30% of cases. Antibiotics were prescribed in 51% of patients. Corticosteroids were prescribed pre intubation in two-thirds of patients and all post intubation, with the median dose being prednisolone 3 mg/kg/day. Primary extubation failure occurred in 6.5% of patients. Neither the duration of intubation nor patient size were associated with extubation failure. An air leak test was performed in 69% of patients and poorly predicted extubation success. One non-urgent tracheostomy was performed and there was one death from hypoxic ischaemic encephalopathy. Endotracheal tube leak is poorly recorded and may not predict successful extubation.

Durability and Measurement Uncertainty of Airtightness in Extremely Airtight Dwellings

In this paper a series of leakage tests is presented on extremely airtight dwellings, studying the durability of the airtightness level and the measurement uncertainty involved. All houses subjected to testing are certificated passive houses, meaning the maximum air leakage rate upon completion was n50 < 0.6 h-1 air changes per hour at 50 Pa pressure difference.In the literature, repeatability and reproducibility issues have been discussed by several authors, along with influences of weather conditions. However, it remains unclear to what extent the available uncertainty intervals are relative or absolute. With the current tendency towards extremely low leakage levels and the introduction of airtightness requirements in building codes, the further exploration of this issue has become crucial.Four aspects concerning air leakage tests are examined: the repeatability and reproducibility of the fan pressurization results in extremely airtight houses, the impact of weather conditions on the measurement results, the impact of the age of the construction, and the reproducibility of the airtightness level in repeated construction of virtually identical houses. The latter is limited to short term effects since all dwellings (n = 15) were completed after 2010.The results show similar relative repeatability and reproducibility intervals to those found in the literature. The rather large effects of weather conditions reported in previous studies could not be reproduced. Normal wear and tear due to occupation of the dwelling proved to introduce substantial relative deterioration of the airtightness of the building shell (20–100% increase in leakage), although in absolute value, the additional leakage was modest and the buildings remained very airtight. In general, it is concluded that pressurization tests render robust results in extremely tight construction, but with respect to ambitious leakage limits, test conditions and small preparation details such as the locking of window hardware can easily determine whether the dwelling will pass or fail.

Use of Barbed Sutures in Laparoscopic Gastrointestinal Single-Layer Sutures.

Background and Objectives:Laparoscopic anastomotic methods are not commonly used because of the cumbersome laparoscopic intracorporeal sutures and tying involved. The barbed suture is one of the various devices developed to simplify the placement of intracorporeal sutures. However, barbed sutures are not commonly used during reconstruction after radical gastrectomy in cancer patients or for single-layer entire-thickness running suturing for intestinal anastomoses. We describe the procedure for using barbed sutures and report on the short-term surgical outcomes.Methods:Between August 2012 and March 2014, 15-cm-long barbed sutures (V-Loc 180; Covidien, Mansfield, MA, USA) were used for laparoscopic intestinal anastomoses, including intestinal hole closure for esophagojejunal and gastrojejunal anastomoses after mechanical anastomoses and gastric wall closure after partial resection.Results:In total, 38 patients underwent 40 laparoscopic anastomoses (esophagojejunostomies, 26; gastrojejunostomies, 7; and simple closure of gastric defect, 7); no cases required conversion to open surgery. Two cases exhibited positive air leak test results during surgery (1 case of esophagojejunostomy and 1 case of simple closure of gastric defect). Two cases of intestinal obstruction were noted; of those, one patient with postoperative intestinal paresis (grade II) was managed conservatively, and the other underwent repeat laparoscopic surgery (grade IIIb) for internal herniation unrelated to V-Loc use. No postoperative complications at the anastomosis site and no surgery-related deaths were noted.Conclusion:Single-layer entire-thickness running suturing with the V-Loc 180 barbed suture after stapled side-to-side intestinal anastomosis was found to be safe and feasible in the reported cases.

Integrated approach to colorectal anastomotic leakage: Communication, infection and healing disturbances.

Colorectal anastomotic leakage (CAL) remains a major complication after colorectal surgery. Despite all efforts during the last decades, the incidence of CAL has not decreased. In this review, we summarize the available strategies regarding prevention, prediction and intervention of CAL and categorize them into three categories: communication, infection and healing disturbances. These three major factors actively interact during the onset of CAL. We aim to provide an integrated approach to CAL based on its etiology. The intraoperative air leak test, intraoperative endoscopy, radiological examinations and stoma construction mainly aim to detect and to prevent communication between the intra- and extra-luminal content. Other strategies including postoperative drainage, antibiotics, and infectious-parameter evaluation are intended to detect and prevent anastomotic or peritoneal infection. Most currently available interventions for CAL focus on the control of communication and infection, while strategies targeting the healing disturbances such as lifestyle changes, oxygen therapy and evaluation of metabolic biomarkers still lack wide clinical application. This simplified categorization may contribute to an integrated understanding of CAL. We strongly believe that this integrated approach should be taken into consideration during clinical practice. An integrated approach to CAL could contribute to a better understanding of the etiology of CAL and eventually better patient outcome.

Can the intraoperative leak test prevent postoperative leakage of esophagojejunal anastomosis after total gastrectomy?

Anastomotic failures that cannot be detected during surgery often lead to postoperative leakage. There have been no detailed reports on the intraoperative leak test for esophagojejunal anastomosis. Our purpose was to investigate the utility of routine intraoperative leak testing to prevent postoperative anastomotic leakage after performing esophagojejunostomy. We prospectively performed routine air leak tests and reviewed the records of 185 consecutive patients with gastric cancer who underwent open total gastrectomy followed by esophagojejunostomy. A positive leak test was found for six patients (3.2%). These patients with positive leak tests were subsequently treated with additional suturing, and they developed no postoperative anastomotic leakage. However, anastomotic leakage occurred in nine patients (4.9%) with negative leak tests. A multivariate analysis demonstrated that a patient age >75years and the surgeon's experience <30 cases were risk factors for anastomotic leakage. Intraoperative leak testing can detect some physical dehiscence, and additional suturing may prevent anastomotic leakage. However, it cannot prevent all anastomotic leakage caused by other factors, such as the surgeons' experience and patients' age.

Intraoperative leak testing has no correlation with leak after laparoscopic sleeve gastrectomy.

Staple line leak is a serious complication of sleeve gastrectomy. Intraoperative methylene blue and air leak tests are routinely used to evaluate for leak; however, the utility of these tests is controversial. We hypothesize that the practice of routine intraoperative leak testing is unnecessary during sleeve gastrectomy. A retrospective cohort study was designed using a prospectively collected database of seven bariatric surgeons from two institutions. All patients who underwent sleeve gastrectomy from March 2012 to November 2014 were included. The performance of intraoperative leak testing and the type of test (air or methylene blue) were based on surgeon preference. Data obtained included BMI, demographics, comorbidity, presence of intraoperative leak test, result of test, and type of test. The primary outcome was leak rate between the leak test (LT) and no leak test (NLT) groups. SAS version 9.4 was used for univariate and multivariate analyses. A total of 1550 sleeve gastrectomies were included; most were laparoscopic (99.8%), except for one converted and two open cases. Routine intraoperative leak tests were performed in 1329 (85.7%) cases, while 221 (14.3%) did not have LTs. Of the 1329 cases with LTs, there were no positive intraoperative results. Fifteen (1%) patients developed leaks, with no difference in leak rate between the LT and NLT groups (1 vs. 1%, p = 0.999). After adjusting for baseline differences between the groups with a propensity analysis, the observed lack of association between leak and intraoperative leak test remained. In this cohort, leaks presented at a mean of 17.3 days postoperatively (range 1-67 days). Two patients with staple line leaks underwent repeat intraoperative leak testing at leak presentation, and the tests remained negative. Intraoperative leak testing has no correlation with leak due to laparoscopic sleeve gastrectomy and is not predictive of the later development of staple line leak.

Laparoscopic Prophylactic Total Gastrectomy in Childhood for the Prevention of Hereditary Diffuse Gastric Cancer

Introduction: Mutations in the E-cadherin (CDH1) gene confer an 80% lifetime risk of hereditary diffuse gastric cancer (HDGC).1 Due to unreliable screening modalities, prophylactic total gastrectomy (PTG) is recommended for individuals at risk for HDGC.2,3 Due to genetic anticipation (cancer occurring at an earlier age with each successive generation), the age at which PTG is recommended is not clearly defined, but generally recommended before 20 years of age.4 We present the case of an asymptomatic 15-year-old male, positive for CDH1 mutation, with a strong family history of HDGC (father and paternal uncle, both died from biopsy-proven diffuse gastric cancer at ages 42 and 15, respectively), who underwent a laparoscopic PTG for the prevention of HDGC. Materials and Methods: Preoperative evaluation included genetic, psychological, endocrine, nutritional, and surgical evaluations; the patient essentially went through our adolescent bariatric surgery program. Upper gastrointestinal endoscopy was unremarkable. His comorbidities included obesity (body–mass index 34 kg/m2), asthma, and depression. A laparoscopic PTG with Roux-en-Y esophagojejunostomy reconstruction was planned. Intraoperatively, with patient in the supine position, five working ports were placed. The gastrocolic ligament was divided and mobilized to the angle of His with division of the short gastric vessels. The duodenocolic ligament was incised, and the first portion of the duodenum was cleared circumferentially and transected 2 cm distal to the pylorus. The right and left gastric vessels were divided. The gastroesophageal junction was cleared circumferentially. An esophagogastroscopy was performed to localize and mark the Z-line, and the distal esophagus was divided with a stapler. A Roux limb was created dividing the proximal jejunum 50 cm distal to the ligament of Treitz. A 150 cm limb was measured, and a side-to-side enteroenterostomy was created with a linear stapler. A window was made in the left mesocolon and 20 cm of Roux limb was passed through this window into the lesser sac. A hand-sewn, two-layered end-to-side esophagojejunostomy was created. An air leak test was performed and no air leaks were identified. The gastrectomy specimen was removed and no intraoperative complications occurred. Results and Conclusions: The operative time was 117 minutes, estimated blood loss was 40 mL, and the patient tolerated the procedure well. A water-soluble contrast esophagogram was performed the following morning, which showed no contrast extravasation. His diet was advanced and he left the hospital without sequelae. Pathologic evaluation of the specimen revealed no invasive cancer. With a mean follow-up of 6 months, no perioperative complications have been identified. In conclusion, laparoscopic PTG can be safely and effectively performed in childhood kindreds at risk for HDGC; until more is known about when these patients develop gastric cancer, strong consideration should be given to perform prophylactic gastrectomy during mid-teenage years in patients with a family history of early gastric cancer. The authors have no conflicts of interest to report. Runtime of video: 5 mins Presented as a video presentation at the International Pediatric Endosurgery Group's (IPEG) 23rd Annual Congress for Endosurgery in Children, held in conjunction with the British Association of Pediatric Surgeons (BAPS). The meeting occurred from July 22–26, 2014 at the Edinburgh International Convention Center (EICC), in Edinburgh, Scotland.

Hartmann's Reversal: Laparoscopic Technique

Introduction: Hartmann's procedure (HP) consists of sigmoidectomy, rectal stump closure, and terminal colostomy. It was originally designed for and performed only in case of neoplastic obstructions. However, over time, indications have expanded and nowadays include complicated diverticulitis, traumatic colonic lesions, volvulus, and perforated rectosigmoid tumors. So there have been a growing number of patients undergoing HP, especially due to the increasing prevalence of sigmoid diverticular disease in the general population. Potentially, all these patients are waiting for their continuity to be restored. The original aim of this procedure was to reduce mortality due to anastomotic dehiscence in an emergent operation for neoplastic obstruction. However, reestablishing continuity after Hartmann's procedure (Hartmann's reversal [HR]) is considered a major surgical procedure and carries serious risk of both morbidity and mortality, ranging from 5% to 50%.1,2 This surely explains why a large proportion of patients undergoing HP will not have their bowel continuity restored. Spreading of laparoscopic expertise along with the documented advantages of minimally invasive approach (decreased postoperative pain, morbidity, hospital stay, and faster return to daily activities) in colonic surgery have lead to its application to procedures, such as HR. Since the first report of laparoscopic HR (LHR), there have been a growing number of publications in the world literature.3–19 This video shows the technique of laparoscopic restoration of bowel continuity after HP. Surgical Technique: The first step of the technique involves mobilization of the colostomy site. This is excised at the mucocutaneous junction circumferentially, until the peritoneum is entered. The edge of the stoma is revised to take away excessive scar tissue. An appropriately sized anvil of a circular stapler is then inserted into the colonic lumen and secured with a purse-string reabsorbable suture. The colostomy site is now used as port site for the establishment of pneumoperitoneum and a trocar or a hand-assist device can be placed for the camera. Three operative trocars are used: a 12-mm trocar in the right lower quadrant, a 10-mm in the right upper quadrant, and a 10-mm in the umbilicus. With the patient in the steep reverse Trendelenburg position, the rectal stump is identified. This step can be facilitated by a suture thread placed at the first surgery (Hartmann) or by transanally inserting a circular stapler, Hegar, dilators, or a rigid sigmoidoscope at HR. Lysis of adhesions is performed with sharp scissor dissection and minimal use of electric current to prevent any injury to the bowel. It is also important to minimize the risk of vascular injury during pelvic dissection, in a subsequent step of the procedure. In case the rectal stump is too long and includes a few folding of the distal sigmoid colon, the latter can be excised using a linear stapler and the specimen brought out through the colostomy site where the hand-assist device can been placed. Subsequently, with the patient in the Trendelenburg position, mobilization of the left colon proximal to the colostomy and take down of the splenic flexure is accomplished, by freeing the lateral attachments, to ensure a tension-free anastomosis with the rectal stump. An end-to-end colorectal anastomosis is created with an appropriately sized endoluminal circular stapler, possibly avoiding a stapler with diameter less than 28–29 mm. The pelvic cavity is filled with the saline solution and the air leak test is done by insufflating the air in the rectum while visualizing the anastomosis. The stoma wound is left partially open. Results: During the 8-year study period, 20 patients underwent laparoscopic HR. The median age was 65.4 years. Ten patients (50%) had undergone surgery for perforated diverticulitis, 3 (15%) for cancer, 7 (35%) for other reasons (volvulus, post-traumatic perforation, sigmoid perforation from foreign body). Previous HP had been performed laparoscopically in only three patients. The median operative time was 162.5 minutes. All the procedures were completed laparoscopically. The intraoperative complication rate was nil. Postoperative mortality and morbidity were 0% and 10%, respectively (one pneumonia, one bowel obstruction from postanastomotic stenosis, which required resection and re-do of the anastomosis). The median time to first flatus was 3 days, to normal diet 5 days. The median hospital stay was 9 days without readmissions. We followed-up the patients for a median of 44 months: when asked, all 20 (100%) said they would undergo the operation (LHR) again; 3 (15%) had been re-operated of laparoscopic mesh repair for incisional hernia. Conclusions: When performed by experienced surgeons, LHR is a feasible, safe, and reproducible operation, which allows early return of bowel function, early discharge, and fast return to work for the patient. It has a low morbidity rate. Drs. Valentino Fiscon, Giuseppe Portale, Antonio Mazzeo, Giovanni Migliorini and Flavio Frigo have no conflicts of interest or financial ties to disclose. Runtime of video: 5 mins 30 secs

Intraoperative Endoscopy Decreases Postoperative Complications in Laparoscopic Roux-en-Y Gastric Bypass.

Leak or stenosis following laparoscopic Roux-en-Y gastric bypass (LRYGB) can lead to a major morbidity. We aim to evaluate whether the routine use of intraoperative endoscopy (IOE) can reduce this morbidity. All cases of LRYGB in 2009-2014 were reviewed. In all cases, we perform an IOE. If IOE shows a leak, the area of the leak is re-enforced and IOE is repeated. If the leak persisted, a feeding tube and drains are placed. During the study period, we performed 342 LRYGB cases. Primary LRYGB represented 82 % (282/342). Average BMI 48 kg/m(2) (range was 35-92) and females represented 76 % (261/342). Our clinical leak rate was 3/342 (0.88 %) in LRYGB (0.4 % in primary and 3.3 % in revisional LRYGB). IOE showed a positive air leak test in six LRYGB cases (1.75 %). We were able to achieve a negative leak test after re-enforcement in 5/6 (83 %) cases, and all those patients had no clinical leak. The patient with persistent air leak test had a clinical leak after surgery. IOE was negative in 336 LRYGB cases and we had two clinical leaks in this group (0.59 %). Our stenosis rate at the gastrojejunostomy was 3/342 (0.88 %). The positive predictive value (PPV) of the performing IOE to detect leaks in LRYGB was 75 % while the negative predictive value was 99.5 %. Routine IOE has led to a change in the operative strategy and could be one reason for our low leak and stenosis in laparoscopic Roux-en-Y gastric bypass.

Change in neck circumference after shoulder arthroscopy: An observational study.

Background and Aims:Shoulder arthroscopy requires fluid irrigation, which causes soft-tissue oedema around chest, neck, and arm intraoperatively, leading to postoperative airway complications. We decided to study the incidence of increase in the neck circumference in shoulder arthroscopy and its effects on the airway.Methods:We studied 32 cases of shoulder arthroscopies over a period of 1-year, performed under general anaesthesia with interscalene block. The neck circumference of patients before and after the procedure was measured along with other parameters. The endotracheal tube cuff was deflated at the end of surgery to determine air leak around the tube. The negative leak test suggested airway oedema.Results:Thirty out of 32 patients showed positive air leak test. The average change in neck circumference was 1.17 ± 1.16 cm and all could be extubated uneventfully. Two showed negative leak test with an increase in neck circumference by 4.5 and 6.4 cm and were not extubated. Multiple regression analysis for risk factors showed intraoperative hypertension as a single predictor for an increase in neck circumference.Conclusion:Change in the neck circumference beyond 4 cm may suggest airway compromise and below 4 cm, airway compromise is unlikely even in the presence of extensive soft-tissue oedema around the shoulder, upper arm and chest.

Changes in intracuff pressure of a cuffed endotracheal tube during prolonged surgical procedures

BackgroundWith the introduction of redesigned cuffed endotracheal tubes (ETTs), there has been an increasing trend toward their use in pediatric patients. Despite improvements in design, an unintended and prolonged hyperinflation of the cuff can compromise tracheal mucosal perfusion. The current study prospectively monitors changes in intracuff pressure continuously in pediatric patients undergoing prolonged surgical procedures. MethodsThe study was conducted on pediatric patients who were scheduled to undergo prolonged surgical procedures (more than 4h) with a cuffed ETT. After placement of the cuffed ETT, the cuff was inflated using the air-leak test with a CPAP of 20cmH2O in the anesthesia circuit. After inflation, the inflating port of the pilot balloon was connected to the transducer of the invasive pressure monitoring device using our previously described technique to continuously measure the intracuff pressure. Measurements were recorded every 15min for the first 1h, and then every 30min throughout the surgical procedure. ResultsThe study cohort included 30 patients who ranged in age from 1.2 to 17.6 years and in weight from 9.4 to 113.4kg. There were 16 boys and 14 girls. The size of the cuffed ETT ranged from 3.5mm to 8.0mm ID. The baseline intracuff pressure at the time of inflation was 17.6±8.8cmH2O. The absolute change in the intraoperative intracuff pressure when compared to the baseline intracuff pressure ranged from −25.8 to +16.3cmH2O. In 9 patients (30%), the decrease of the intracuff pressure was ≥10cmH2O. In 6 patients (20%), the increase of the intracuff pressure was ≥10cmH2O. In 5 of 30 patients (17%), the absolute intracuff pressure was greater than 30cmH2O at least once intraoperatively. In no patient, did the intracuff pressure remain the same as the baseline throughout the procedure. ConclusionWe noted significant variations in the intracuff pressure during prolonged surgical procedures. These unintended changes, both increases and decreases, may impact the perioperative course of patients. Our study suggests the need for continuously monitoring intracuff pressure if a cuffed ETT is used in children for prolonged surgical procedures.

Prospective randomized comparison of gastrotomy closure associating tunnel access and over-the-scope clip (OTSC) with two other methods in an experimental ex vivo setting.

Background: Safe transgastric natural orifice transluminal endoscopic surgery (NOTES) procedures require a reliable closure of the gastrotomy. Recently a novel peritoneal access method via a submucosal tunnel has been described with encouraging preliminary results. Aim: The aim is to compare a submucosal tunnel access plus over-the-scope clip (OTSC) system for closure with two other closure modalities. Patients and methods: This is a prospective ex vivo study conducted on 42 porcine stomach models equally randomized into three groups in an academic medical center. The procedures performed in each group included: (1) Tunnel (6 cm) + endoclips; (2) Knife + balloon dilation access + OTSC; and (3) Tunnel + OTSC. A pressurized air-leak test was performed to evaluate the strength of the closure. Stomach volumes, procedure times, number of clips, and incision sizes were also registered. Results: The mean air-leak pressure was statistically higher in Group 3 than in Groups 1 and 2–95.2 ± 19.3 mmHg versus 72.5 ± 35.2 and 79.0 ± 24.5 mmHg (P < 0.05). The gastrotomy creation times for Groups 1, 2, and 3 were 28.0 ± 10.1, 4.3 ± 1.4, and 20.1 ± 10.6 minutes, respectively, with significantly lower time in Group 2 (P < 0.001). The closure times were 16.1 ± 6.1, 6.5 ± 1.2, and 5.3 ± 3.0 minutes, respectively, and significantly longer in the endoclip group (P < 0.001). There were no differences in the volumes and the incision sizes among the three groups. Conclusion: The combination of a submucosal tunnel access and OTSC offers a stronger closure than the other methods studied.

The effect of an enclosure retrofit on air leakage rates for a multi-unit residential case-study building

This paper presents a relatively new, simple and robust, method for air leakage testing. A thirteen-story multi-unit residential building was tested for air leakage before and after an enclosure retrofit. The building suites had a pre-retrofit NLA50 average of 6.77cm2/m2 and an average post-retrofit NLA50 of 2.82cm2/m2—a 58% betterment. The effect of the retrofit on air leakage rates was assessed and compared to other multi-unit residential buildings across Canada and USA. The case study building was significantly tighter than other multi-unit residential buildings included in published studies. Recommendations were made for field-testing procedures in order to maximize the potential for accurate measured flow characteristics. Field-testing for air-tightness needs to be standardized in order for useful comparative results to be generated in order to inform future research and operational considerations for the multi-unit residential building stock across North America.

What Is the Risk of Clinical Anastomotic Leak in the Diverted Colorectal Anastomosis?

ObjectiveThe objective of this study was to identify clinical leak in diverted colorectal anastomoses. DesignCohort analysis. SettingThe study was conducted in a subspecialty practice at a tertiary care facility. PatientsConsecutive subjects undergoing colorectal anastomosis and proximal fecal diversion between July 16, 2007 and June, 31 2012. InterventionsNo intervention was applied. Main Outcome MeasuresClinical anastomotic leak. ResultsTwo hundred forty-five patients underwent a colorectal anastomosis with proximal fecal diversion. A total of 34 (14 %) clinical leaks were identified at a median of 43 days. Clinical leaks were identified in 13 (5 %) patients within 30 days of surgery (early leaks) and in 21 (9 %) patients after 30 days of surgery (late leaks). Age, sex, use of neoadjuvant chemoradiotherapy, and method of anastomotic construction were similar in patients with clinical leaks as compared to those with no evidence of leak. However, clinical leaks were more likely to develop in patients with a diagnosis of inflammatory bowel disease or other diagnoses, i.e., radiation enteritis, ischemia, and injury/enterotomy. Patients with clinical leak were not more likely to have air leaks on intraoperative air leak testing. ConclusionsIn diverted anastomoses, most leaks become clinically apparent beyond 30 days. The standard practice of censoring outcomes that occur beyond postoperative day 30 will fail to identify a substantial fraction of leaks in diverted colorectal anastomoses.

Airtightness in New and Retrofitted U.S. Army Buildings

The Engineer Research and Development Center, Construction Engineering Research Laboratory (ERDC-CERL) recently developed design/construction strategies that improve the energy efficiency, reduce the potential for mould, and improve indoor air quality in newly constructed buildings and buildings undergoing major renovations. ERDC-CERL performed building envelope leakage tests on Army facilities to test their general integrity and the effect of increased airtightness on building energy consumption. Results were used to develop airtightness criteria and performance requirements for new construction and major renovation projects, which have been included in Army design/construction strategies.Since 2009, the U.S. Army Corps of Engineers (USACE) has implemented an airtightness requirement in all new construction and building enclosure renovation projects. Engineering and Construction Bulletin (ECB) 2012–16 set levels of airtightness for building enclosures at the material, assembly, and system level. ECB 2012–16 requires whole building air leakage tests to be conducted at completion of construction to verify the constructed air barrier system’s performance. The current Air Leakage Test Protocol for Building Envelopes developed by ERDC-CERL, the Air Barrier Association of America (ABAA), and other industrial partners was published in May 2012.This paper presents the results of airtightness tests before and after the new requirements were established, updated results for air leakage tests of more than 285 newly constructed and renovated large buildings, and a performance analysis of the design and construction process, air barrier materials, building use, and construction types. These data may support future decisions regarding airtightness levels to be adopted for commercial buildings.