Initiation Of Oral Intake Research Articles

Effect of oral intake initiation-establishment interval on hospital stay after oral cancer surgery.

To clarify the effect of the period between initiation of oral intake (IOI) and establishment of oral intake (EOI) on length of hospital stay. This retrospective study included postoperative oral cancer patients. The number of days from surgery to IOI and EOI and between IOI and EOI were recorded. We performed intergroup comparisons and Cox regression analysis using the number of days until discharge, representing hospital stay length as the dependent variable. The median number of days between IOI and EOI was 3 days for eligible patients and 4.5 and 1.5 for older and younger patients, respectively. The median number of days from surgery to IOI was 15 days. There was a significant correlation between the period between IOI and EOI and the length of hospital stay (r = 0.40, p < 0.01). The period between IOI and EOI was a significant independent variable for the length of hospital stay (HR [95% confidence interval] = 0.45 [0.28-0.72]). Shortening the IOI to EOI intervals was identified as an independently associated factor for shortening hospital stay, even in older postoperative patients with dysphagia who struggled with early oral intake initiation. Professional, step-by-step dysphagia rehabilitation tailored to the patient's condition yields beneficial outcomes.

Early feeding after free flap reconstruction of the oral cavity: A systematic review and meta-analysis.

Traditionally, patients undergoing free flap reconstruction for oral cavity defects have been given nothing by mouth for 6-14 days post-operatively due to concern for orocutaneous fistula development. Multiple databases were screened for studies assessing the rate of orocutaneous fistula formation in early (≤5 days) versus late (>5 days) feeding groups following oral cavity free flap reconstruction. Fixed- and random-effects meta-analyses were used. One randomized controlled trial, one prospective cohort, and three retrospective cohort studies were included. The early feeding group displayed no significant increase in orocutaneous fistula formation (RD = -0.02, p = 0.06) or free flap failure (RD = -0.01, p = 0.39), with a significantly shorter hospital length of stay (mean difference [days] = -2.43, p < 0.01). While further prospective trials are necessary, initiation of oral intake before post-operative day 5 may be appropriate in properly selected patients following oral reconstruction.

Effectiveness of Scheduled Early Ambulation on Maternal Outcomes in Post caesarean in Odisha, Eastern India

Abstract Background: Scheduled early ambulation on the day of surgery in post-operative women showed expedited recovery and prevented complications amongst women and newborns. Objectives: The study aimed to evaluate the effectiveness of scheduled early ambulation on maternal outcomes amongst post-caesarean women. Methods: A quasi-experimental post-test-only time series design was adopted. Post-caesarean women (142) were recruited to the experimental group (n 1 = 71) and the control group (n 2 = 71). Scheduled early ambulation was initiated from the day of surgery in the experimental group, while the control group received standard care. Post-operative recovery was assessed in both groups by a demographic pro forma, post-operative assessment tool and physical well-being tool. Results: The present study findings revealed a remarkable improvement in maternal outcomes such as a significant reduction in the mean post-operative pain score, speedy involution of the uterus, breastfeeding, lochia, first bowel movement, moving independently from the bed, catheter removal, initiation of oral intake and physical well-being amongst the women in the experimental compared to the control group. Conclusion: A scheduled early ambulation is crucial for improving maternal outcomes and restoring the sense of well-being in women after caesarean section (CS). The primary caregiver and health professionals should promote it to encourage women after CS to reduce post-operative complications and speedy recovery.

Antimesenteric sleeve tapering enteroplasty with end-to-end anastomosis versus primary end-to-side anastomosis for the management of jejunal/ileal atresia

Background/objectiveSmall bowel atresia commonly causes neonatal intestinal obstructions. Technical problems are associated with the surgical management of atresia using primary end–to–end anastomosis. Furthermore, the significantly dilated proximal loop may be associated with the stasis of intestinal fluid, thus increasing pressure on the anastomosis and prolonging fasting time before initiation of oral intake. This study aimed to perform antimesenteric tapering of the proximal loop using a linear stapler to reduce its diameter and facilitate anastomosis with the distal loop. MethodsThis retrospective study included 57 neonates diagnosed with jejunoileal atresia. They were categorised into two groups: Group A (n = 29), which included neonates treated using antimesenteric sleeve enteroplasty tapering using a linear stapler and Group B (n = 28), which included neonates treated at the primary end of the proximal loop to the side of the distal loop anastomosis. ResultsThe mean operative time was 122.5 min in group A vs. 118 min in group B, and the mean duration to reach full oral intake was 17 days in group A vs. 20.2 days in group B (p = 0.03). The mean length of hospital stay was 25 and 35 days in groups A and B, respectively (p = 0.042). ConclusionTapering the proximal dilated bowel loop to achieve anastomosis with the distal loop improved the transient time, reduced stasis and its associated translocation and colonisation, and allowed for early initiation and maintenance of oral intake. All these parameters shortened the overall length of hospital stay.

Door-to-oral time and in-hospital outcomes in older adults with aspiration pneumonia undergoing dysphagia rehabilitation

Aspiration pneumonia (AP) is a public health concern among older adults. Previous studies have reported the association between oral intake initiation within 48h after hospital admission and better in-hospital outcomes among patients with AP. We investigated the association between initiation of oral intake within 24h and in-hospital outcomes of older patients with AP undergoing dysphagia rehabilitation. This retrospective cohort study was conducted from April 2015 to September 2020. Door-to-oral time (D2O) was defined as the time from hospital arrival to the first oral intake and was divided into early (within 24h), middle (between 24 and 48h), and late (over 48h). We examined the associations between D2O and in-hospital outcomes: discharge with oral intake (by logistic regression analysis), length of stay, and days from the first oral intake to discharge (by fitting the general linear models with robust variance estimation). Among the 398 patients with AP, 142 (35.7%) were classified into early, 111 (27.9%) into middle, and 145 (36.4%) into late groups. Compared with the late group, we found insufficient evidence that early D2O was associated with a greater likelihood of discharge with oral intake (adjusted odds ratio=1.09; 95% confidence interval [95% CI]: 0.50 to 2.38). The early group was associated with a shorter length of stay (adjusted length difference [aLD]=-7.14 days; 95% CI:-10.80 to-3.42) but not with shorter days from first oral intake to discharge (aLD=-3.34 days; 95% CI:-6.91 to 0.24). While D2O within 24h among patients with AP was not associated with a decreased likelihood of discharge with oral intake, it was associated with a shorter length of stay. To improve outcomes without compromising the quality of AP care, early oral intake should be decided based on careful swallowing function assessment.

Continuous Versus Intermittent Nutrition in Pediatric Intensive Care Patients: Protocol for a Randomized Controlled Trial.

BackgroundIntermittent fasting is a time-restricted feeding strategy with proven health benefits, which is based on multiple metabolic and endocrine changes, in several patient populations and healthy participants. In the pediatric intensive care unit (PICU), artificial feeding is usually administered 24 hours a day, although solid evidence supporting this practice is lacking. This discards the potential benefits of fasting in this population. We hypothesize that intermittent nutrition with a focus on an overnight feeding interruption (intermittent fasting), as compared with 24-hour continuous nutrition, is a feasible and safe strategy, with potential benefits, for critically ill children.ObjectiveThe aim of the Continuous versus Intermittent Nutrition in Pediatric Intensive Care randomized controlled trial (RCT) is to investigate a strategy of intermittent nutrition with a focus on an overnight feeding interruption period versus 24-hour nutrition during the first 14 days in the PICU.MethodsThe Continuous versus Intermittent Nutrition in Pediatric Intensive Care study is an investigator-initiated RCT in a tertiary referral PICU. Critically ill children (term newborn to 18 years), expected to stay in the PICU for ≥48 hours, and dependent on artificial nutrition, are eligible for inclusion. This study will randomize critically ill children (n=140) to a continuous versus intermittent nutrition strategy. In both groups, similar daily caloric targets will be prescribed. In the continuous group (control), nutrition will be administered 24 hours a day, with a maximum interruption period of 2 hours. In the intermittent group (intervention), nutrition will be interrupted during an age-dependent overnight fasting period. The study intervention will last until admission day 14, initiation of oral intake, or discharge from the PICU, whichever comes first. The primary outcome is the difference in ketosis between the groups under the condition of noninferiority regarding caloric intake. Secondary outcomes are feeding intolerance; the proportion of severe and resistant hypoglycemic events and severe gastrointestinal complications; and additional observed effects on nutritional intake, circadian rhythm, and clinically relevant outcome measures of the intermittent feeding strategy compared with continuous nutrition.ResultsThe study was approved by the Dutch national ethical review board in February 2020. The first patient was enrolled on May 19, 2020. By May 2022, a total of 132 patients had been included in the study. Recruitment of the last patient is expected in Q3 2022.ConclusionsAlthough intermittent fasting has been proven to have many health benefits in both animal and human studies, the feasibility and safety of this strategy in a PICU setting must be investigated. This RCT will help physicians gain more insight into the feasibility, safety, and potential clinical effects of intermittent feeding with overnight fasting in critically ill children.Trial RegistrationNetherlands Trial Register NL7877; https://trialsearch.who.int/Trial2.aspx?TrialID=NL7877International Registered Report Identifier (IRRID)DERR1-10.2196/36229

Compare outcome in patients of ileostomy and colostomy closure with surgical stapler versus ileostomy and colostomy closure with hand sewn anastomosis: a prospective study

Background: Diverting temporary stoma is created to protect the primary bowel pathology and distal anastomosis. Once that primary pathology has been overcome or distal anastomosis gets healed, closure of temporary stomas can be carried out. Invention of stapling devices for intestinal anastomosis provided another dimension than hand sewn method to the stoma closure techniques. In this study, we have compared two methods of loop stoma closure-hand sewn method versus stapler method.Methods: This is prospective comparative study in which 50 cases of loop ileostomy/colostomy were taken. 25 patients underwent ileostomy/colostomy closure by hand sewn anastomosis (group A). Another 25 patients underwent ileostomy/colostomy closure by stapler anastomosis (group B). Time taken for operation, initiation of oral intake, anastomotic leak, post-operative wound infection and total hospital stay duration were compared between these two groups to conclude about which method is superior and in the best interest of patient and surgeon.Results: Mean operation time 105.96 minutes (group A) and 72.84 minutes (group B). Mean time to start oral intake 5.36 days (group A), 3.6 days (group B). 16% patients (4/25) group A and 4% patients (1/25) group B developed anastomotic leak. 28% patients (7/25) group A and 8% patients (2/25) group B had post-operative wound infection. Mean hospital stay 10.4 days in group A and 7.84 days in group B.Conclusions: Stapler method provides significant benefits in terms of less operative time, early oral intake and less hospital stay. Overall stapler method for stoma closure is more efficient and cost effective.

Comparison of Transanal Minimally Invasive Surgery (TAMIS) and Transanal Endoscopic Operations (TEO)

Rectal lesions, benign or malignant, are one of the most encountered clinical entities in general surgery departments. Technological breakthroughs in local excision techniques have been occurring such as transanal endoscopic microsurgery (TEM), transanal minimally invasive surgery (TAMIS), and transanal endoscopic operations (TEO) during the last two decades. We compared the results between TAMIS and TEO for removing rectal lesions. The study was conducted on patients who underwent TAMIS and TEO interventions due to rectal lesions between 2010 and 2015 in the Department of General Surgery of Gulhane Military Medical Academy and the University of Ankara. The data for these patients relating to their age, gender, distance from the anal verge, operation time, occurrence of first bowel movement after surgery, initiation of oral intake after surgery, length of hospital stay, tumor size, follow-up, complications, free resection margin, recurrence, postoperative Fecal Incontinence Severity Index (FISI) and visual analog scale (VAS) scores, and pathologic specimen examination were taken from the hospital’s electronic database. All data were enrolled and analyzed statistically. The TAMIS group had 23 (54.8%) patients, and the TEO group had 19 (45.2%) patients. The TAMIS operation time was significantly longer than that of TEO (Z = 3.188; P < 0.001). Median time to first bowel movement in the TAMIS group was 36.0 h (interquartile range (IQR) = 12.0) vs. 24.0 h (IQR = 18.0) in the TEO group; the difference was significant (Z = 3.358; P = 0.001). No significant differences were found between the two groups in complication rate, recurrence, visual analog scale, or Fecal Incontinence Severity Index. TAMIS and TEO techniques have been found to produce almost similar results. These two techniques are considered to be good alternatives to conservative treatment methods with their reliability and feasibility in experienced hands for selected patients. For TAMIS and TEO techniques to qualify as “treatment of choice,” prospective randomized clinical trials are needed.

Initiation of Oral Intake in Patients Using High-Flow Nasal Cannula: A Retrospective Analysis

Purpose High-flow nasal cannula (HFNC) is beneficial for critically ill patients in respiratory distress. Because the effects of HFNC on swallowing are unclear, speech-language pathologists lack th...

Early Assessment and Management of Dysphagia After Lung Resection: A Randomized Controlled Trial

Aspiration resulting from oropharyngeal dysphagia has been recognized as a serious complication after lung resection. The primary aim of this study was to determine whether early detection of postoperative dysphagia would reduce pneumonia among these patients. The median length of hospital stay was assessed. In this single-center, randomized controlled trial, the experimental group underwent clinical assessment of dysphagia before the initiation of oral intake after surgery. Therapeutic interventions were implemented immediately for patients diagnosed with dysphagia. The risk of pneumonia and the median length of hospital stay were compared between the 2 groups. Between February 2014 and May 2016, 438 patients were randomized. Complete data from all randomized patients were analyzed. Eight cases out of 219 (3.7%) with postoperative dysphagia were detected in the experimental group. Pneumonia occurred in 14 cases out of 219 (6.4 %) in the experimental group and in 27 cases out of 219 (12.3 %) in the control group. The resulting risk reduction for pneumonia was 5.9% in the experimental group (95% confidence interval, 0.44-11.56; P= .033). The median length of hospital stay was 6 (5-8 [25th-75th percentile]) days in the experimental group and 7 (5-10 [25th-75th percentile]) days in the control group (P=.083). Early detection of postoperative dysphagia can significantly decrease the risk of postoperative pneumonia in patients undergoing lung resection.

Effects of early oral feeding versus delayed feeding on gastrointestinal function of post-caesarean section women in a tertiary hospital in Enugu, Nigeria: A randomized controlled trial.

Initiation of oral intake after caesarean delivery influences return of bowel function, ambulation of patients, and time to recover from surgery. To assess the effect of early versus delayed initiation of oral feeding after caesarean delivery on gastrointestinal function, pace of recovery, and maternal satisfaction at University of Nigeria Teaching Hospital (UNTH), Enugu. This was a randomized controlled study of women who had caesarean delivery from December 2012 to September 2013 at the Department of Obstetrics and Gynaecology UNTH, Enugu, Nigeria. In all, 282 participants were randomized equally into early and delayed oral feeding groups. Oral intake was commenced at 8 h post operation for those in early feeding group and at 48 h post operation for those in delayed feeding group. The primary outcome measure was the time interval from the end of surgery to the return of bowel sound. Analysis was by intention-to-treat. SPSS version 16 was used for data entry and analysis was done using cross tabulation and Fisher's exact test for categorical data and independent sample T-test for continuous data. P value of < 0.05 was regarded as statistically significant. Apart from gastrointestinal complications, there was significant difference between early and delayed feeding groups with respect to all the outcome variables: return of bowel sound (17.8 ± 4.3 h vs 35.2 ± 9.4 h; P < 0.001), return to regular diet 48.9 ± 5.2 h vs 85.5 ± 7.0 h; P < 0.001), postoperative time interval to ambulation (20.3 ± 7.0 h vs 30.9 ± 9.6 h; P < 0.001), and maternal satisfaction as estimated with visual analog scale (86.4 ± 10.4 mm vs 40.0 ± 25.9 mm; P < 0.001). Early initiation of oral feeding after caesarean delivery is safe and may be associated with earlier return of bowel functions, earlier ambulation, shorter postoperative time interval to become eligible for discharge, and high maternal satisfaction.

A Multimodal Analgesic Pathway Improves Postpartum Pain Management Scores as Reflected by HCAHPS scores

Background: Postpartum pain is an important issue in obstetrics. A standardized method of monitoring pain scores is provided by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) national survey. In an effort to improve pain management ans subsequently improve HCAHPS scores in our obstetrics unit, we implemented a multimodal analgesic pathway with the intent to maximize analgesia while minimizing opioid use. Methods: Traditional postpartum analgesia methods were replaced with a multimodal pathway, including patientcontrolled epidural anesthesia for the first 12-24 hours after cesarean delivery plus acetaminophen and ketorolac IV as needed. Upon initiation of oral intake, scheduled acetaminophen and ibuprofen are administered. Transdermal lidocaine patches and opioids are added as needed. The oral medication pathway is initiated following vaginal delivery. Baseline and post-implementation responses to HCAHPS pain management questions 1) How often was your pain well controlled? 2) How often did the hospital staff do everything they could to help you with your pain were compared. Results: Prior to analgesia protocol implementation, pain management scores were below the desired benchmark of 78%. Post-implementation, responses of “Always” or “Top-box” for Question 1 significantly increased [73% versus 65%; p=0.05]. Post-intervention Top-box responses for Question 2 increased from 82% to 89% (p<0.03). Conclusions: The development of a postpartum multimodal analgesic regimen resulted in significantly improved pain management scores, reflected by HCAHPS scores. No other systematic intervention occurred to explain these positive changes.

Clinical Effect of Water-Soluble Contrast Agents for Small Bowel Obstruction in the Virgin Abdomen.

Several studies have investigated the diagnostic and therapeutic role of water-soluble contrast agents (WSCAs) in adhesive small bowel obstruction (SBO). However, the clinical effect of WSCA for SBO without previous intraabdominal operation (i.e., virgin abdomen, VA) is unclear. The aim of this study was to clarify the clinical effect of WSCA for SBO in the VA. Between January 2008 and December 2015, 838 consecutive patients with SBO were initially managed with WSCA and were included in the study. Abdominal X-rays were taken 5h after administration of 100ml WSCA and classified into complete/incomplete obstruction groups. The medical records of the patients with SBO were retrospectively analyzed and divided into two groups of patients with VA or non-VA. A total of 44 and 794 VA and non-VA patients were identified, respectively. Six VA patients (13%) and 121 non-VA patients (15%) were classified with complete obstruction (p=1.000) and subjected to operative exploration on the same day. There were no significant differences in the duration of nasogastric tube decompression (2.2 versus 2.5days, p=0.400) and intervals until the initiation of oral intake (2.4 versus 2.6days, p=0.553) between the VA and non-VA groups. The overall operative rate was 16% in the VA and 17% in the non-VA groups (p=1.000). Compared with non-VA, VA was associated with shorter hospital stays (9.6 versus 11.3days, p=0.006). WSCA for SBO in the VA is as effective as in non-VA patients in terms of a therapeutic strategy.

Factors involved in the discontinuation of oral intake in elderly patients with recurrent aspiration pneumonia: a multicenter study.

PurposeTo assess the factors involved in oral intake discontinuation in elderly patients with recurrent aspiration pneumonia.Patients and methodsThis study included patients with pneumonia who were treated at Jichi Medical University Hospital between 2007 and 2013, at Toyooka Public Hospital between 2011 and 2013 and at Yuzawa Community Medical Center between 2010 and 2012. We consecutively enrolled patients with aspiration pneumonia. The primary study point was oral intake discontinuation after the initiation of oral intake during hospitalization in cases of recurrent aspiration. Various parameters were recorded at admission, at the initiation of intake, and during hospitalization; these parameters were statistically evaluated.ResultsA total of 390 patients were assigned to either a “no reaspiration of intake” group (n=310) or a “reaspiration of intake” group (n=80), depending on whether intake was discontinued owing to aspiration during hospitalization. At admission, the following items significantly differed between the groups: level of consciousness, respiratory rate, oxygen saturation, CURB-65 score, extent of infiltration/opacity on chest radiography, albumin levels, blood urea nitrogen levels, and application of swallowing function assessment. At the initiation of intake, level of consciousness, pulse rate, and albumin levels significantly differed between the groups. The following items did not significantly differ between groups: systolic blood pressure, pulse rate, C-reactive protein, bacteremia, use of ventilator at admission, oxygen administration, respiratory rate, and systolic blood pressure at initiation of intake. Multivariate analysis revealed that application of swallowing function assessment, level of consciousness at the initiation of intake, and extent of infiltration/opacity on chest radiography were significant predictive variables for discontinuation of intake.ConclusionA low level of consciousness at the initiation of intake and a greater extent of infiltration/opacity on chest radiography and the application of a swallowing function are important factors. These factors may be helpful to determine a suitable timing for resumption of oral intake.

Feasibility of laparoscopic and endoscopic cooperative surgery for gastric submucosal tumors (with video)

Laparoscopic gastric resection is widely used for gastric submucosal tumors (SMTs). However, determining an appropriate resection line using only the laparoscopic approach is difficult. We developed a laparoscopic and endoscopic cooperative surgery (LECS) technique by combining laparoscopic gastric resection with endoscopic submucosal dissection, and we have used this procedure to resect gastric SMTs. In this study, the procedure is presented and its safety and feasibility for resecting gastric SMTs are evaluated. This retrospective study included 100 patients who underwent LECS for SMTs at the Department of Gastroenterological Surgery, Cancer Institute, between June 2006 and November 2014. The demographics, tumor histopathologic characteristics, and operative and follow-up data were reviewed. Complete resection with negative surgical margins was achieved in all patients, and LECS was performed regardless of tumor location. The mean operation time was 174.3 minutes, with an estimated blood loss of 16.3mL. In addition, the mean time until the initiation of oral intake was 1.4 days, and the mean postoperative hospital stay was 8.4 days. Moreover, no local or distant tumor recurrence was observed. The only severe adverse event was leakage, which was observed in 1 patient. LECS was performed with a reasonable operation time, low blood loss, and minimal adverse events. Therefore LECS is safe and feasible for resecting gastric SMTs.

The efficacy of continuous subcostal transversus abdominis plane block for analgesia after living liver donation: a retrospective study.

Postoperative pain management for living liver donors has become a major concern as a result of the increasing number of living liver donations. Transversus abdominis plane (TAP) block has been known to provide effective analgesia for abdominal surgery. The aim of this study was to evaluate the efficacy of ultrasound-guided continuous subcostal TAP block as a part of a multimodal analgesic regimen in comparison with conventional intravenous (IV) fentanyl-based analgesia in living liver donors. Thirty-two donors were retrospectively classified into either the continuous subcostal TAP block group (TAP group) or the IV fentanyl-based analgesia group (control group). TAP group donors received bilateral continuous subcostal TAP infusion of 0.125% levobupivacaine at 6ml/h. Control group donors did not receive any neural blockade. Cumulative fentanyl consumption was significantly lower in the TAP group for 48h (P<0.01) as compared to the control group. Further, the donors in the TAP group had significantly lower incidence of nausea and vomiting during 24-48h postoperatively (P<0.01) and fewer delays in the initiation of oral intake than those in the control group (P=0.02). In conclusion, continuous subcostal TAP block provided an effective opioid-sparing analgesia for living liver donors.

Randomized trial of two swallowing assessment approaches in patients with acquired brain injury: Facial-Oral Tract Therapy versus Fibreoptic Endoscopic Evaluation of Swallowing

Objective: To examine whether patients assessed for initiation of oral intake only by Facial-Oral Tract Therapy had a greater risk of developing aspiration pneumonia during neurorehabilitation than patients assessed by Fibreoptic Endoscopic Evaluation of Swallowing. Design: Randomized controlled trial. Setting: Specialized, national neurorehabilitation centre. Subjects: Adult patients with acquired brain injury. Six hundred and seventy-nine patients were assessed for eligibility and 138 were randomly allocated between June 2009 and April 2011. Interventions: Assessment by Facial-Oral Tract Therapy (control group) or Fibreoptic Endoscopic Evaluation of Swallowing (intervention group). Main measure: Primary outcome was the number of aspiration pneumonias that developed after initiation of oral intake. Results: One hundred and nineteen patients were included in the analysis of the primary outcome (62 controls/57 interventions). Sixteen patients were clinically diagnosed with pneumonia (4 controls/12 interventions). Nine patients had to be excluded: 6 patients got pneumonia before initiating oral intake; 3 patients with the clinical diagnosis of pneumonia did not show radiological signs. Seven patients were left for analysis, 4 of whom developed aspiration pneumonia within 10 days after initiating oral intake (1 control/3 interventions). Conclusion: In the presence of a structured clinical assessment with the Facial-Oral Tract Therapy approach, it is unnecessary to undertake an instrumental investigation of swallowing before initiation of oral intake.

Comparison of retroperitoneal and transperitoneal approach for reconstruction of abdominal aortic aneurysm in patients with previous laparotomy

Although the standard surgical approach for repair of infrarenal abdominal aortic aneurysm (AAA) has been the transperitoneal approach, several reports have suggested the usefulness of retroperitoneal aortic reconstruction. However, the superiority of the retroperitoneal compared with transperitoneal approach is still controversial. To compare the efficacy of the retroperitoneal with that of the transperitoneal approach in elective AAA resection, 19 consecutive cases with previous laparotomies were randomly reviewed. From January 1990 through December 1992, 94 consecutive patients underwent elective reconstructions of an infrarenal AAA. Among them, 75 patients had had no previous surgery of any kind. In all of them, the transperitoneal approach was used (Group I). Nineteen other patients who had various laparotomies were randomly divided into two groups. The transperitoneal approach was used in 10 patients (Group II), and the retroperitoneal approach was used in 9 patients (Group III). Thus, the patients were separated into three groups and the intra- and postoperative parameters were compared. Surgical data including operative time, intraoperative blood loss, and aortic cross-clamping time did not differ significantly between the transperitoneal approach in the patients without laparotomy (Group I) and the retroperitoneal approach (Group II). In addition, the postoperative recovery including the initiation of alimentation and postoperative hospitalization also did not differ significantly between the two groups. However, there was a significant difference in the operative time and the blood loss between the retroperitoneal approach (Group II) and transperitoneal approach (Group III) in the patients with previous laparotomy. In addition, the postoperative parameters including the initiation of oral intake was sooner and hospitalization was significantly shorter in the retroperitoneal group (Group II) than in the transperitoneal group (Group III) with previous laparotomy. There was no incidence of postoperative adhesive ileus in the patients with the retroperitoneal approach (Group II). The results demonstrated no important advantage for the retroperitoneal approach compared with routine transperitoneal approach in the patients without previous laparotomy. However, in the patients with previous laparotomies, the retroperitoneal approach is a preferable alternative to the transperitoneal route.

Laparoendoscopic Single-Site Radical Nephrectomy: A Comparison with Conventional Laparoscopy

To study the feasibility and safety of laparoendoscopic single-site (LESS) radical nephrectomy, we compared the operative results with conventional laparoscopic radical nephrectomy. Ten patients underwent LESS radical nephrectomy for renal tumors (group 1). Two types of single-port devices, a SILS port and a homemade single-port device that was made using a surgical glove and a wound retractor, were used through a 4-cm periumbilical incision. The operative results of LESS radical nephrectomy matched those of 12 patients who underwent conventional laparoscopic radical nephrectomy (group 2). For comparing the 2 groups, the Mann-Whitney U test and the Fisher exact test were used. LESS surgeries were completed successfully, without conversion to conventional laparoscopic or open surgery. The patients' characteristics did not differ significantly between the two groups. The mean operative times in groups 1 and 2 were 127.7 ± 22.3 minutes and 126.1 ± 43.1 minutes, respectively (P = 0.235). The mean estimated blood loss was 185.7 ± 121.9 mL and 324.0 ± 187.0 mL, respectively (P = 0.65). The complication rates were 10% and 17%, respectively (P = 0.658). The mean times to postoperative initiation of ambulation and initiation of oral intake were not different in the two groups (1.1 vs 1.0 days, P = 0.269; 1.0 vs 1.0 day, P = 1.0). The mean lengths of hospital stay were 6.5 and 6.1 days (P = 0.435). The mean tumor sizes were 4.0 cm and 5.2 cm (P = 0.345). LESS radical nephrectomy is technically feasible and comparable to conventional laparoscopy. Long-term follow-up and technical development, however, are needed for assessing the cancer-control effect and facilitating the minimal invasiveness of the surgery.

当科における喉頭全摘術後の合併症の検討

Introduction: We examined post-total laryngectomy complications. By using PGE1 during the perioperative period, we made it possible to achieve complication-free laryngeal surgery for patients with radiation failure. We now present our evaluation of complication frequencies of patients with radiation failure and those without it.Patients and Methods: Our work was a retrospective chart review of 37 patients who underwent total laryngectomy in our hospital from 2001 to 2008. These included 24 patients who underwent surgery for primary treatment and 12 patients who underwent salvage surgery due to radiation failure. The remaining one patient had laryngo-pharyngeal stenosis after radiation therapy for hypopharyngeal cancer and underwent total laryngectomy as a salvage surgery. One T2, 9 T3 and 14 T4 cases underwent surgery for primary treatment and 2 T2, 5 T3 and 5 T4 cases underwent salvage surgery. Closure of the hypopharyngeal mucosa was performed using 4-0 silk and no other procedures were conducted to reinforce the wound.Results: As for 24 patients who underwent primary treatment, a minor leakage and a pharyngo-cutaneous fistula were observed in two patients who had active diabetes mellitus and their initiation of oral intake were on the 17th post-operative day (POD) and the 34th POD, respectively. Their days of discharge were also prolonged to the 30th POD and the 50th POD, respectively. One patient had a subcutaneous abscess around his tracheostoma and the commencement of his oral intake and day of discharge were prolonged to the 13th POD and the 28th POD. Another patient also had a subcutaneous abscess and his day of discharge was prolonged to the 36th POD. The average number of days to begin oral intake after surgery was 9.1 days and the average number of days until discharge after surgery were 23.3 days. However, with 13 patients who underwent salvage surgery and had no leakage or other wound complications the average number of days to discharge after surgery was 20.8 days.Discussion: According to our protocols for laryngectomies, the administration of PGE1 during the perioperative period, even for patients with radiation failure that had no wound complication, shortened the time to discharge from the hospital. Since diabetes mellitus seemed to be a key factor in wound complication after laryngectomies, even for patients undergoing primary treatment, we must consider new methods for treating them.