Late Postoperative Phase Research Articles

Bone Marrow Aspirate Concentrate Does Not Improve Osseous Integration of Osteochondral Allografts for the Treatment of Chondral Defects in the Knee at 6 and 12 Months: A Comparative Magnetic Resonance Imaging Analysis

Background: Poor osseous integration after fresh osteochondral allograft transplantation (OCA) may be associated with graft subsidence and subchondral bone collapse after implantation. The augmentation of OCA with bone marrow aspirate concentrate (BMAC) has been hypothesized to improve osseous incorporation of the implanted allograft. Purpose: To evaluate the effect of autogenous BMAC treatment on osseous integration at the graft-host bony interface after OCA. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of patients treated with OCA+BMAC or OCA alone for full-thickness chondral defects of the distal femur from March 2015 to December 2016 was conducted. Seventeen knees treated with OCA+BMAC and 16 knees treated with OCA alone underwent magnetic resonance imaging (MRI) in the early postoperative phase (mean, 6 months). Eighteen knees treated with OCA+BMAC and 16 knees treated with OCA alone underwent MRI in the late postoperative phase (mean, 12 months). Bone, cartilage, and ancillary features on MRI were graded using the Osteochondral Allograft MRI Scoring System (OCAMRISS) by a musculoskeletal radiologist blinded to the patient’s history and treatment. Results: There were no significant differences in the demographics or lesion characteristics between treatment groups in either postoperative phase. In the early postoperative phase, the mean OCAMRISS bone score was 3.0 ± 0.7 and 3.3 ± 0.7 for the OCA+BMAC group and OCA alone group, respectively (P = .76); 71% (OCA+BMAC) and 81% (OCA alone) of MRI scans demonstrated discernible clefts at the graft-host junction (P = .69), and 41% (OCA+BMAC) and 25% (OCA alone) of MRI scans demonstrated cystic changes at the graft and graft-host junction (P = .46). In the late postoperative phase, the mean OCAMRISS bone score was 2.7 ± 0.8 and 2.9 ± 0.8 for the OCA+BMAC group and OCA alone group, respectively (P = .97); 44% (OCA+BMAC) and 63% (OCA alone) of MRI scans demonstrated discernible clefts at the graft-host junction (P = .33), and 50% (OCA+BMAC) and 31% (OCA alone) of MRI scans demonstrated the presence of cystic changes at the graft and graft-host junction (P = .32). The mean OCAMRISS cartilage, ancillary, and total scores were not significantly different between groups in either postoperative phase. Conclusion: OCA augmented with BMAC was not associated with improved osseous integration; decreased cystic changes; or other bone, cartilage, and ancillary feature changes compared with OCA alone.

Perioperative antiemetic efficacy of dexamethasone versus 5-HT3 receptor antagonists: a meta-analysis and trial sequential analysis of randomized controlled trials.

Dexamethasone has many desirable pharmacologic properties for perioperative use. Its antiemetic potential has been a focus of many recent trials. Trials comparing dexamethasone to 5-HT3-receptor antagonists (5HT3-RA) for 24h postoperative vomiting incidences published till August 2017 were searched in the medical database. Comparisons for antiemetic efficiency variables (vomiting incidence, nausea incidence, rescue antiemetic need, and patients with complete response) during early (until 6h) and late postoperative phase were made. Comparative analgesic requirements were also evaluated. Twenty randomized controlled double-blinded trials were included in the final analysis. Twenty-four-hour vomiting incidence was similar (Fixed-effects, P = 0.86, I2= 2.94%). Trial sequential analysis (TSA) confirmed non-inferiority of dexamethasone for 24-h vomiting incidence. (α = 5%, β = 20%, δ = 10%) with "information size" being 1619 (required > 573). Equivalence was also verified from early and delayed nausea rate as well using TSA. Pooled results did not demonstrate superiority/inferiority of 5-HT3-RAs over dexamethasone in all other antiemetic efficacy variables (early and delayed). Heterogeneity was found to be low in all of the comparisons. Linear-positive dose-response curve for dexamethasone 24-h vomiting and nausea incidence was seen (correlation coefficient being 0.21 and 0.28, respectively). Dexamethasone reduced the analgesic need (MH-odds of 0.64 (95% CI being 0.44 to 0.93) P = 0.02, I2 = 0)). Possibility of publication bias could not be ruled out (Egger's test, X-intercept = 1.41, P = 0.04). Dexamethasone demonstrates equal antiemetic efficacy compared to 5-HT3 receptor antagonists. The agents perform equally well both in early postoperative phase and up to 24h after surgery. Use of dexamethasone replacing 5-HT3 RAs offers an additional advantage of lowering the opioid requirements during the perioperative period.

Lung function in the late postoperative phase and influencing factors in patients undergoing pulmonary lobectomy.

Lung function in the late postoperative phase after pulmonary lobectomy is insufficiently characterized. This study aimed to appraise lung function in the late postoperative phase according to vital capacity (VC) and forced expiratory volume in 1 second (FEV1) in patients who underwent pulmonary lobectomy. Pre- and postoperative VC and FEV1 were reviewed in 112 patients who underwent pulmonary lobectomy. Postoperative lung volume was assessed >1 year after surgery. Postoperative decreases in VC and FEV1 were compared with preoperative predicted values among patients who underwent resection of specific lobe. Determinants effecting a decrease in lung function were also investigated. A mean postoperative decreased VC of 10.5%±1.8% was recorded in patients who underwent right upper lobectomy (RU), 7.2%±1.5% for right middle lobectomy (RM), 14.3%±2.3% for right lower lobectomy (RL), 16.6%±3.0% for left upper lobectomy (LU), and 14.7%±2.5% for left lower lobectomy (LL). Corresponding FEV1 values were 14.8%±1.8% for RU, 11.9%±4.0% for RM, 14.9%±2.3% for RL, 17.9%±2.9% for LU, and 15.1%±2.4% for LL. The actual decreasing rate of VC was overestimated in patients who underwent RU, RL, LU, and LL. In contrast, FEV1 was overestimated only in patients who underwent RL and LL. Patients with chronic obstructive pulmonary disease (COPD) exhibited significantly better preservation of FEV1. Patients scheduled for RL and LL, or those with COPD, appeared to exhibit preserved lung function in the late postoperative phase after pulmonary lobectomy.

Haloperidol Versus 5-HT3 Receptor Antagonists for Postoperative Vomiting and QTc Prolongation: A Noninferiority Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials.

Haloperidol is an antipsychotic with well-known antiemetic potential. It is underutilized for postoperative nausea vomiting due to reported corrected QT interval (QTc) prolongation. This meta-analysis evaluates its safety and efficacy as an antiemetic in the perioperative period. Trials comparing haloperidol to 5-HT3 -receptor antagonists (5-HT3 -RA) for 24 postoperative vomiting incidences published up to May 2017 were searched in the medical database. Comparisons were made for antiemetic efficiency variables (vomiting incidence, rescue antiemetic need, and patients with complete response) during early (until 6 hours) and late postoperative phases. Eight randomized controlled double-blinded trials were included in the final analysis. Twenty-four-hour vomiting incidence was similar in groups (fixed effects, P = 0.52, I2 = 0%). Trial-sequential analysis confirmed noninferiority of haloperidol over 5-HT3 -RAs (α = 5%, β = 20%, δ = 10%), with "information size" being 859 (required > 812). Pooled results did not demonstrate superiority/inferiority of 5-HT3 -RAs over haloperidol in all other antiemetic efficacy variables (early and delayed). Negligible heterogeneity was found in all the comparisons made. Pooled Mantel Haenszel odds ratio for QTc prolongation was equivalent in both groups (fixed effects, P = 0.23, I2 = 0%). The mean dose of haloperidol used was 1.34 mg, and no trial reported extrapyramidal side effects. Trial-sequential analysis showed statistical equivalence (α = 5%, β = 20%, δ = 10%), with information size being 745 (required > 591). Publication bias was unlikely (Egger test, X-intercept = 2.07, P = 0.10). We conclude that haloperidol is equivalent to the well-established 5-HT3 -RAs in preventing vomiting during the first day after surgery. The incidence of QTc prolongation with haloperidol is statistically equivalent to 5-HT3 -RAs and thus should not be the factor that discourages its use for treatment/prophylaxis of postoperative nausea vomiting.

Longitudinal analysis of serum oxylipin profile as a novel descriptor of the inflammatory response to surgery

BackgroundOxylipins are potent lipid mediators demonstrated to initiate and regulate inflammation yet little is known regarding their involvement in the response to surgical trauma. As key modulators of the inflammatory response, oxylipins have the potential to provide novel insights into the physiological response to surgery and the pathophysiology of post-operative complications. We aimed to investigate the effects of major surgery on longitudinal oxylipin profile.MethodsAdults patients undergoing elective laparoscopic or open colorectal resections were included. Primary outcomes were serum oxylipin profile quantified by ultra high-performance liquid chromatography-mass spectrometry, serum white cell count and C-reactive protein concentration. Serum samples were taken at three time-points: pre-operative (day zero), early post-operative (day one) and late post-operative (day four/five).ResultsSome 55 patients were included, of which 33 (60%) underwent surgery that was completed laparoscopically. Pre-operative oxylipin profiles were characterised by marked heterogeneity but surgery induced a common shift resulting in more homogeneity at the early post-operative time-point. By the late post-operative phase, oxylipin profiles were again highly variable. This evolution was driven by time-dependent changes in specific oxylipins. Notably, the levels of several oxylipins with anti-inflammatory properties (15-HETE and four regioisomers of DHET) were reduced at the early post-operative point before returning to baseline by the late post-operative period. In addition, levels of the pro-inflammatory 11-HETE rose in the early post-operative phase while levels of anti-thrombotic mediators (9-HODE and 13-HODE) fell; concentrations of all three oxylipins then remained fairly static from early to late post-operative phases. Compared to those undergoing laparoscopic surgery, patients undergoing open surgery had lower levels of some anti-inflammatory oxylipins (8,9-DHET and 17-HDoHE) in addition to reduced concentrations of anti-thrombotic mediators (9-HODE and 13-HODE) with increased concentration of their pro-thrombotic counterpart (TxB2).ConclusionsSerum oxylipin profile is modified by surgical intervention and may even be sensitive to the degree of surgical trauma and therefore represents a novel descriptor of the surgical systemic inflammatory response.

Prospective analysis of postoperative outcomes – immediate / delayed in patients undergoing Lichtenstein’s open inguinal hernioplasty using Vypro® vs Prolene® mesh

As we advance towards improving inguinal hernia repair our goals remain to decrease the immediate post-operative complications like pain and seroma formation; and at the same time preventing long term complications like chronic groin pain and hernia recurrence. We present in our study comparision of outcomes in the immediate and late post-operative phase of 50 patients [25 - prolene® and 25 - vypro®] who underwent lichtenstein’s inguinal hernia. Our results did encourage the lightweight mesh like vypro® in the immediate post-operative phase but did not give any major difference between the meshes in the long term complications or outcomes of hernia repair. Our observations were similar to other studies done comparing the various mesh used for hernia repair.

Imaging of the postoperative liver: review of normal appearances and common complications

Several benign and malignant liver diseases may require surgical treatment for cure, including anatomical resections based on the segmental anatomy of the liver, non-anatomical (wedge) resections, and surgical management of biliary cysts. The type of surgery depends not only on the location and the nature of the disease, but also on the expertise of the surgeon. Whereas ultrasonography is often the first-line imaging examination in case of suspected postoperative complication, multidetector computed tomography (MDCT) is of greater value for identifying normal findings after surgery, early postoperative pathologic fluid collections and vascular thromboses, and tumor recurrence in patients who have undergone hepatic surgery. Magnetic resonance cholangiopancreatography (MRCP) is the imaging modality of choice for depicting early postoperative bile duct injuries and ischemic cholangitis that may occur in the late postoperative phase. Both MDCT and MRCP can accurately depict tumor recurrence. Radiologists should become familiar with these surgical procedures to better understand postoperative changes, and with the normal imaging appearances of various postoperative complications to better differentiate between complications and normal findings.

Benefit and Safety of Dual Antiplatelet Therapy after Coronary Artery Bypass Grafting for Off-pump CABG: A Systematic Review and Meta-analysis

Aims: This study aims to evaluate benefit and safety compared dual antiplatelet therapy with single aspirin therapy after coronary artery bypass grafting. Study Design: A systematic review and Meta-analysis. Place and Duration of Study: Medline, Embase, ScienceDirect and Cochrane Library databases were searched for randomized controlled trials or observational studies focusing on anticoagulant therapy after coronary artery bypass grafting until December 2014. Methodology: Endpoints included postoperative mortality, bleeding events, myocardial infraction, stroke, repeat revascularization and graft occlusion. All these endpoints were compared between dual antiplatelet therapy and single aspirin therapy. Newcastle-Ottawa and Jadal scale were used to assess the quality of observational studies and randomized controlled trials respectively. Software R2.15.2 was utilized for Meta-analysis. Results: 15 studies composed of 31,365 patients were included. Compared with single aspirin Original Research Article Wang et al.; BJMMR, 9(11): 1-15, 2015; Article no.BJMMR.19433 2 therapy, dual antiplatelet therapy resulted in reducing risk of vein graft occlusion (OR=0.53, 95%CI 0.36-0.81, P=0.001), but no significant difference for artery graft occlusion (OR=0.91, 95%CI 0.392.12, P=0.882), Risk of postoperative mortality (OR=0.57, 95%CI 0.38-0.85, P=0.006) and repeat revascularization (OR=0.15, 95%CI 0.05-0.45, P=0.001) was also reduced. There were no significant difference for MI (OR=0.77, 95%CI 0.55-1.09, P=0.137), Stroke (OR=0.85, 95%CI 0.601.19, P=0.330) and bleeding (OR=0.95, 95%CI 0.82-1.09, P=0.465). In subgroup analysis of offpump CABG, dual antiplatelet therapy reduced risk of graft occlusion (OR=0.49, 95%CI 0.30-0.82, P=0.006), MI (OR=0.28, 95%CI 0.11-0.72, P=0.009), mortality (OR=0.39, 95%CI 0.25-0.60, P<0.001), and did not increase risk of bleeding (OR=0.75, 95%CI 0.55-1.02, P=0.066). Conclusions: Dual antiplatelet therapy reduced risk of postoperative graft occlusion and mortality in the early and late postoperative phase after CABG. It appeared to be more beneficial for offpump CABG.

Reoperation after mitral valve repair in viewpoints of kidney injury as well as hemolytic anemia.

A 70-year-old woman developed anemia and kidney injury 10months after mitral valve (MV) repair. Serological findings and Doppler echocardiography suggested hemolytic anemia due to mitral regurgitation jet collision with an annuloplasty ring (MRCR). Since kidney injury persisted even without exacerbation of anemia over 10months, we performed an MV replacement. The anemia improved rapidly after the surgery; however, the renal function remained chronic kidney disease (CKD) after reoperation. Kidney injury was thought to be due to iron deposition and decreased renal perfusion that caused tubular injury. A comprehensive literature review shows that hemolysis due to MRCR in the early postoperative phase (within 3 postoperative months) can be often ameliorated with endothelialization without the need for reoperation; however, hemolysis in the late postoperative phase can persist even for a long period without reoperation. Chronic hemolysis can lead to kidney injury and progress to CKD even without clinical evidence of exacerbation of anemia. Therefore, in cases of late postoperative phase hemolysis, reoperation should be considered for better management of kidney injury and hemolytic anemia.

Is Pylorus-preserving Gastrectomy Universally Applicable to Early Gastric Cancer of the Mid Stomach?

Recent advances in endoscopic diagnosis have allowed gastric cancer to be diagnosed early, often in asymptomatic patients. Currently, endoscopic mucosal resection and endoscopic submucosal dissection are accepted as the least invasive procedures when managing early gastric cancer (cT1). An important intermediate option before open gastrectomy is laparoscopic gastrectomy. Advanced laparoscopic gastrectomy contributes to both improved esthetics and earlier postoperative recovery. However, quality of life is mainly affected by late-postoperative phase complications, such as dumping syndrome and loss in body weight resulting from reduced oral intake. Pylorus-preserving gastrectomy (PPG), with limited stomach resection and lymph node dissection, is an example of function-preserving surgery that can improve late-postoperative phase function. In general, PPG is applicable to patients who were preoperatively diagnosed with cT1N0M0 primary gastric cancer in the middle third of the stomach, when the distal tumor border is C4 cm away from the pylorus. During the procedure, infrapyloric vessels are routinely preserved to maintain a suitable blood supply to the pyloric cuff, as is the root of the right gastric artery. Furthermore, the hepatic and pyloric branches of the vagus nerves are routinely preserved. More recently, laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) with lymphadenectomy has presented an attractive option. Several groups have indicated that LAPPG is a feasible and reliable procedure with satisfactory postoperative symptoms and functional outcomes. However, the incidence of metastasis in the preserved regional lymph nodes remains an obstacle to the wider application of the function-preserving surgery. In particular, lymph nodes at the suprapyloric and infrapyloric stations may be incompletely dissected when preserving nerve and arterial branches in either PPG or LAPPG. Therefore, metastatic tumor in residual suprapyloric and infrapyloric lymph nodes may contribute to disease recurrence in patients who undergo PPG. Although several studies have indicated acceptable long-term outcomes and survival rates after both PPG and LAPPG, neither has gained widespread use in standard clinical practice. Recently, Kim et al. attempted to evaluate the status of micrometastasis in suprapyloric and infrapyloric lymph nodes in early gastric cancers that are located in the mid stomach and managed with PPG. They found that the mean number of collected suprapyloric lymph nodes was significantly lower after PPG than with conventional distal gastrectomy; the findings were not significant for infrapyloric lymph nodes. Moreover, they determined that all metastasis (both macro and micro) to suprapyloric and infrapyloric lymph nodes are essentially very rare and that the long-term survival of patients after PPG was acceptable. They concluded that micrometastasis to the suprapyloric and infrapyloric lymph nodes may be negligible, and that PPG may be a safe procedure for early gastric cancer located in the mid stomach. This study essentially supports earlier work evaluating the oncological reliability of PPG. However, this study should be interpreted with caution because it was retrospective in design and involved a single-center cohort with a relatively small number of patients. Furthermore, the study failed to completely assess the primary tumor location (e.g., lesser curvature side, anterior wall). When evaluating a surgical procedure in a single-center study, results can be biased by the surgical skill base at that institution. In particular, LAPPG is a technically difficult surgery for inexperienced surgeons, involving precise Society of Surgical Oncology 2013

Risk factors for acute renal injury in living donor liver transplantation: evaluation of the RIFLE criteria

Acute renal injury (ARI) is a serious complication after liver transplantation. This study investigated the usefulness of the RIFLE criteria in living donor liver transplantation (LDLT) and the prognostic impact of ARI after LDLT. We analyzed 200 consecutive adult LDLT patients, categorized as risk (R), injury (I), or failure (F), according to the RIFLE criteria. ARI occurred in 60.5% of patients: R-class, 23.5%; I-class, 21%; and F-class, 16%. Four patients in Group-A (normal renal function and R-class) and 26 patients in Group-B (severe ARI: I- and F-class) required renal replacement therapy (P < 0.001). Mild ARI did not affect postoperative prognosis regarding hospital mortality rate in Group A (3.2%), which was superior to that in Group B (15.8%; P = 0.0015). Fourteen patients in Group B developed chronic kidney disease (KDIGO stage 3/4). The 1-, 5- and 10-year survival rates were 96.7%, 90.6%, and 88.1% for Group A and 71.1%, 65.9%, and 59.3% for Group B, respectively (P < 0.0001). Multivariate analysis revealed risk factors for severe ARI as MELD ≥ 20 [odds ratio (OR) 2.9], small-for-size graft (GW/RBW <0.7%; OR 3.1), blood loss/body weight >55 ml/kg (OR 3.7), overexposure to calcineurin inhibitor (OR 2.5), and preoperative diabetes mellitus (OR 3.2). The RIFLE criteria offer a useful predictive tool after LDLT. Severe ARI, defined beyond class-I, could have negative prognostic impact in the acute and late postoperative phases. Perioperative treatment strategies should be designed and balanced based on the risk factors for the further improvement of transplant prognosis.

Study of dural sac cross-sectional area in early and late phases after lumbar decompression surgery

Background contextLumbar magnetic resonance imaging (MRI) in the early phase after lumbar decompression surgery sometimes reveals an absence in the expansion of the dural sac, regardless of the presence or absence of clinical symptoms; the reason for such a condition is often difficult to explain. There are some reports that compared the dural sac area between the preoperative and early postoperative phases; however, no report exists that compares the early and late phases after lumbar decompression surgery. PurposeThe purpose of this study was to compare changes in the dural sac cross-sectional area (CSA) in the early and late phases after lumbar decompression surgery. Factors related to the insufficient increase in the postoperative dural sac CSA were also analyzed. Study designThe dural sac CSA preoperatively and in the early and late phases after lumbar decompression surgery was analyzed retrospectively. Patient sampleOf 105 patients who underwent lumbar decompression surgery and MRI within 1 week and again more than 1 month after surgery, 83 patients (38 men, 45 women; mean age 65.6 years) were included in this study. Outcome measuresCross-sectional areas of the dural sac. MethodsThe dural sac CSA was measured within 1 week (early phase) and more than 1 month (late phase) after surgery, using T2 axial plane MR images. The preoperative and the early and late postoperative CSAs were measured at the same site. The relationship between the dural sac area and age and presence of dural injury was also analyzed. ResultsThe mean area of the dural sac preoperatively and in the early and late postoperative phases was 71.2±4.9, 102.2±5.7, and 164.1±6.9 mm2, respectively. The mean area increased significantly (p<.001) between the preoperative and postoperative early phases and between the early and late postoperative phases. The dural sac area in the early (p=.16) and late (p=.086) phases did not differ significantly between patients aged 75 years or more and those aged less than 75 years. In the case of lumbar spinal stenosis, patients with a preoperative dural sac area of less than 60 mm2 showed a significantly (p<.001) smaller dural sac area in the early and late postoperative phases, compared with patients with a preoperative dural sac area of 60 mm2 or more. No significant increase was observed in the dural sac area with regard to the presence or absence of dural injury. ConclusionsThe dural sac area increased significantly between the early and late postoperative phases. No significant difference in the dural sac CSA between the early and late postoperative phases was observed with regard to age or the presence/absence of dural sac injury. A smaller preoperative dural sac CSA resulted in a smaller dural sac CSA in the early and late postoperative phases.

Nucleated cells circulating in the peripheral blood contribute to the repair of osteochondral defects only in the early phase of healing

The role of cells circulating in the peripheral blood to participate in the natural repair process of osteochondral defects was evaluated in a green fluorescent protein (GFP) transgenic and wild rat parabiosis model. Two weeks after the parabiosis operation, vascular communication between the conjoined rats was confirmed by flow-cytometry analysis. A 1.5 mm diameter and 1.0 mm depth osteochondral defect was made in the patellar groove of each rat femoral bone. Histological examination was performed at 1, 2, 4 and 24 weeks following surgery. In the early postoperative phase (1-4 weeks) there were GFP-negative and -positive cells in the defects of both parabiotic rats. GFP-positive chondrocytes were confirmed partly in the repair tissue of the wild parabiotic rat. In the late postoperative phase (24 weeks), the repaired defects were occupied by cells originating from the adjacent tissue and not from the peripheral blood. The ratio of cells originating from the peripheral blood was approximately 30-40% in the repair tissue at 1 week after surgery, reduced to 0-7% at 24 weeks. From these results it is confirmed that cells circulating in the peripheral blood contributed to the repair of the osteochondral defects, particularly in the early phase of healing. Thus, peripheral blood not only supplies the factors needed for repair but also provides a cell population involved in the wound-healing process.

Analysis of Shortened Versions of the Tampa Scale for Kinesiophobia and Pain Catastrophizing Scale for Patients After Anterior Cruciate Ligament Reconstruction

Recent work suggests that psychological influence on pain intensity and knee function should be considered for patients after anterior cruciate ligament reconstruction (ACLR). The Tampa Scale for Kinesiophobia (TSK) and Pain Catastrophizing Scale (PCS) have been used to determine psychological influence in these patients. However, TSK and PCS factor structures have not been described for patients with ACLR. This study investigated 2 groups of patients post-ACLR to determine if the use of shortened questionnaires is warranted. Cross-sectional study in which patients completed measures during early (n=105, median days from surgery=56.0) and late (n=184, median days from surgery=195.0) postoperative phases of ACLR rehabilitation. Shortened questionnaires for fear of pain, fear of injury, and somatic focus were generated for the TSK-11. A shortened questionnaire for magnification/helplessness and rumination was generated for the PCS in the late group only. There were minimal differences in the shortened questionnaires for clinical subgroups based on sex, ACLR graft type, method of injury, or nature of injury. Correlation and regression analyses suggested a shortened version of the TSK-11 for fear of injury was appropriate for use in the early postoperative phase, whereas the original TSK-11 scale may be appropriate for use in the late postoperative phase. There were no shortened versions of the PCS for consideration in the early postoperative phase, but a shortened version for magnification/helplessness was appropriate for use in the late postoperative phase. Shortened versions of the TSK-11 and PCS may be appropriate for ACLR populations, depending on the postoperative phase. These data may guide future research of psychological factors in ACLR populations so that levels predictive of risk for developing chronic pain and/or inability to return to pre-injury activity levels can be determined.

Ability of patients to retain and recall new information in the post-anaesthetic recovery period: a prospective clinical study in day surgery*

Patients are frequently told new information in the early postoperative period and may retain little of it. Two hundred patients undergoing general anaesthesia for day surgery procedures were randomly allocated into two equal groups, 'Early' and 'Late'. Both groups were asked to undertake a simple memory test either in the early or late postoperative phase of their recovery. A list of five objects was verbally presented and recall of these five objects was tested after 30 min. A control group of 100 patients performed the same test. Patients in the control group received no sedative medications. Statistically significant differences (p < 0.001) in recall ability were demonstrable between each of the three groups. Twenty-three percent of patients in the 'Early' group had total amnesia of any test information given. Only 1% of the 'Late' group were unable to remember any information; a mean interval of 40 min separated the two groups. We recommend that verbal information given postoperatively be delayed until a recovery interval of at least 40 in, and should be supported with written material.

Persistent renin-angiotensin system activation after anti-reflux surgery and its management

Purpose To study renin-angiotensin system activation and the role of angiotensin-converting enzyme inhibition (ACE-I) after anti-reflux surgery. Material and Methods Thirty nine children underwent anti-reflux surgery for high grades of primary VUR. Plasma renin activity (PRA), urinary microalbumin, renal scars, split renal function (SRF), glomerular filtration rate (GFR), serum creatinine, blood pressure and episodes of breakthrough urinary tract infection were monitored in the early (5.9 ± 3.9; range 3–9 months) and late (27.1 ± 6.5; range 15–36 months) postoperative phase, before and after therapy with ACE-I (mean period 13.6 ± 2.5; range 10–24 months). Results The early postoperative improvement in renal parameters (rise in SRF and GFR by 11.2% and 7.3%, respectively, and fall in PRA by 68.8%), was not sustained subsequently (minimal improvement in SRF, 7.4%, and GFR, 0.14%, was accompanied by a rise in PRA by 92.3%). After ACE-I therapy, improvement was noted in SRF and GFR by 0.5% and 7.5%, respectively, and there was a fall in urinary microalbumin by 52.3%. Conclusions Significant down regulation of rennin-angiotensin system activation and the accompanying improvement in renal function seen early after surgery is not sustained during follow up. ACE-I aids renal recovery.

Feasibility of Intraoperative MRI Guidance for Craniotomy and Tumor Resection in the Semisitting Position

Intraoperative magnetic resonance imaging (iMRI) has emerged as a reliable and useful tool in intracranial brain tumor surgery. Patient placement in a semisitting position may be advantageous in certain cases, but has so far seemed incompatible with conductance of iMRI-guided procedures. The general iMRI setup and the imaging protocol were tested and described earlier. Having performed a preliminary phantom study and a minimally invasive burr-hole procedure in the semisitting position, we have transferred our setup into craniotomy: an iMRI-guided microsurgical tumor resection was performed in a patient with a recurrent glioblastoma in the occipital lobe extending to the corpus callosum using a mobile 0.15 Tesla iMRI system. All safety precautions commonly used in semisitting craniotomy were also applied. Patient positioning as well as preoperative and intraoperative image acquisition could be accomplished. Tumor resection was performed in a standard microsurgical image-guided manner using neuronavigation. On intraoperative imaging, we could demonstrate complete resection of enhancing tissue, which was later confirmed by early postoperative high-field MRI. After our established protocol of patient monitoring, no complications or adverse events were noted intraoperatively or in the early or late postoperative phases. The iMRI-guided brain tumor resection is feasible in combination with semisitting patient positioning. However, special safety precautions must be followed.

Antibody-mediated rejection presenting as allograft hydronephrosis

An 18-year-old boy underwent living-donor renal transplantation. His mother was the donor. The patient was started on tacrolimus (0.1 mg/kg/d), prednisolone (20 mg/d) and azathioprine (2 mg/kg/d), after initial 3 days of I.V. methyl prednisolone (15 mg/kg/d), as immunosuppressive regimen. Six months after transplantation, he presented with fever that had occurred for two days. There was no history of dysuria, altered urine colour, pyuria or edema. Serum creatinine increased from 1.0 mg/dl to 1.9?2.8?3.7 mg/dl over the next 3 days. On the day of admission, serum tacrolimus levels, blood and urine cultures, and search for polyoma virus were ordered. A Doppler ultrasound of the renal allograft artery revealed a resistive index of 0.9 and hydronephrosis, which had not been present on any of the previous ultrasound exams. A CT scan of the abdomen, with an empty urinary bladder, confirmed hydronephrosis of the allograft, with possible pelvic ureteric junction obstruction (Fig. 1). Blood clots, a technically poor ureteral implantation and ureteral are common causes of obstruction in the early post operative phase, whereas periureteral fibrosis, lymphocele and calculi are possible causes in the late post-operative phase. On the same day, the renal transplant surgeon reviewed the operation protocol notes and confirmed that an antireflux procedure, the Lich reimplantation, had indeed been performed. The radionuclide micturition cystography did not reveal vesicoureteral reflux. Ureteric stenosis due to polyoma virus–associated nephropathy (PVAN) was provisionally diagnosed. However, it is known that PVAN typically induces stenosis in the distal rather than the proximal part of the ureter [1, 2]. On day two, the polyoma virus DNA was found to be negative in both urine and blood. Blood and urine cultures were also sterile. Serum tacrolimus levels were found to be 1.8 ng/l. Circulating donor-specific antibodies determination was unfortunately not available in our hospital. The allograft biopsy was done, under ultrasound guidance, and it revealed neutrophils in the capillaries and in the interstitium, diffuse acute tubular injury and C4d positivity in peritubular capillaries. PVAN may be differentiated from acute antibody-mediated rejection (AMR), but not from acute cellular rejection, by the presence of mononuclear and plasma cell infiltration. After renal transplantation, the ureter receives its entire blood supply from the ureteral branch of the renal artery [3]. Acute rejection involves both the kidney and the ureter, and the resulting edema and possible secondary ischaemia may also lead to ureteral obstruction [3]. In an animal model, Hricak et al. [4], found significant alterations in the ureteral dynamics during rejection, as shown by the progressive decrease in electrical activity of the ureteral muscle on electromyography and the reduced G. Swarnalatha R. Ram (&) B. H. Santosh Pai V. Ramesh K. V. Dakshinamurty Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad 082, India e-mail: ram_5_1999@yahoo.com

Quality of life and patient satisfaction with enhanced recovery protocols

The aim of this study was to systematically review the literature on the influence of enhanced recovery after surgery (ERAS) protocols and health related quality of life (HQoL) and patient satisfaction. A systematic review of the literature from January 1990 to February 2009 was undertaken. Studies were included if they compared HQoL and/or patient satisfaction after ERAS and conventional surgery (CS). Jadad score was used to evaluate the studies. Results were divided into immediate (first week), early (second to third week) and late (more than 30 days after surgery) post-operative phases. A meta-analysis was not possible due to the heterogeneity of the studies. Ten publications were included in the final analysis. In the first week after surgery, two non-randomised trials found reduced fatigue and another 2 non-randomised studies found reduced pain with ERAS. One randomised study found increased emotional distress on SF36 in ERAS patients. At two to three weeks after surgery, none of the multidimensional HQoL measures showed any differences. Increased fatigue was reported with CS in 2 studies. Limitations in activities of daily living were more marked after CS in one study. Beyond 30 days after surgery, none of the HQoL measures showed any differences. Only one non-randomised study compared patient satisfaction after ERAS and CS and no difference was found. There is no evidence that ERAS adversely affect HQoL or patient satisfaction. Certain aspects of HQoL such as pain and fatigue may improve with ERAS. Further research is required, especially in the early post-operative period.

Cerebrovascular Complications After Heart Transplantation

Neurological complications in orthotopic heart transplantation represent a major cause of morbidity and mortality despite successful transplantation. The most frequent perioperative neurological complications are delirium or encephalopathy. In this period cerebrovascular complication ranges between 5-11%. After the perioperative period, the 5-year stroke risk after cardiac transplantation is 4.1%. In a retrospective study conducted with 314 patients who underwent cardiac transplantation, it was found that 20% of cerebrovascular complications occurred within the first two weeks after transplantation, while 80% occurred in the late postoperative phase. Of these, ischemic stroke is the most common subtype. In the perioperative periode, hemodynamic instability, cardiac arrest, extracorporeal circulation over 2 hours, prior history of stroke, and carotid stenosis greater than 50% have been reported to be risk factors for the occurrence of cerebrovascular complications. Perioperative cerebrovascular complications are associated with higher mortality and poor functional outcome at one year follow-up.After the perioperative period, the only factor that has been significantly associated with an increased risk of cerebrovascular complications is a history of prior stroke, either ischemic or hemorrhagic. Other associated factors include unknown atrial fibrillation, septic emboli from endocarditis, cardiac catheterization and perioperative hemodynamic shock. According to the TOAST etiologic classification, the most prevalent etiologic subtype of ischemic stroke is undetermined cause.