Major Open Abdominal Surgery Research Articles

Role of GIRK Channels in Addictive Substance Effects

G-protein-activated inwardly rectifying potassium (GIRK) channels are widely expressed in the central nervous system, including brain regions related to reward, and play an important role in mediat- ing the signal transduction pathways of various addictive substances. Studies of GIRK knockout mice have suggested the involvement of GIRK channels in the mechanisms that underlie the effects of addictive substances. Human studies have shown that differences in the genetic sequence of one of the four GIRK channel subunits, GIRK2, are asso- ciated with analgesic requirements in patients who undergo major open abdominal surgery. Animal and human studies also showed the possi- ble therapeutic effects of GIRK channel inhibitors in the treatment of methamphetamine dependence and alcoholism. These findings suggest that GIRK channels may be a key molecular target in the reward system for the treatment of addiction.

Major Complications, Mortality, and Resource Utilization After Open Abdominal Surgery

To assess the association of 0.9% saline use versus a calcium-free physiologically balanced crystalloid solution with major morbidity and clinical resource use after abdominal surgery. 0.9% saline, which results in a hyperchloremic acidosis after infusion, is frequently used to replace volume losses after major surgery. An observational study using the Premier Perspective Comparative Database was performed to evaluate adult patients undergoing major open abdominal surgery who received either 0.9% saline (30,994 patients) or a balanced crystalloid solution (926 patients) on the day of surgery. The primary outcome was major morbidity and secondary outcomes included minor complications and acidosis-related interventions. Outcomes were evaluated using multivariable logistic regression and propensity scoring models. For the entire cohort, the in-hospital mortality was 5.6% in the saline group and 2.9% in the balanced group (P < 0.001). One or more major complications occurred in 33.7% of the saline group and 23% of the balanced group (P < 0.001). In the 3:1 propensity-matched sample, treatment with balanced fluid was associated with fewer complications (odds ratio 0.79; 95% confidence interval 0.66-0.97). Postoperative infection (P = 0.006), renal failure requiring dialysis (P < 0.001), blood transfusion (P < 0.001), electrolyte disturbance (P = 0.046), acidosis investigation (P < 0.001), and intervention (P = 0.02) were all more frequent in patients receiving 0.9% saline. Among hospitals in the Premier Perspective Database, the use of a calcium-free balanced crystalloid for replacement of fluid losses on the day of major surgery was associated with less postoperative morbidity than 0.9% saline.

Adult Live Donor Hepatectomy: A Retrospective Pilot Study Comparing Four Strategies of Perioperative Pain Control

Purpose: To compare the post operative pain control of four distinct management strategies in adult live donor hepatectomy. Methods: Sixty-two ASA physical status I and II patients undergoing live donor hepatic resection from 2001 to 2008 were retrospectively organized into four groups for post-operative pain control. Group A received epidural catheter, Group B received PCA, Group C received intraoperative dexmedetomidine and PCA, and Group D received perioperative gabapentin, intraoperative dexmedetomidine, and PCA. Four day postoperative visual analog pain scores (VAS), intravenous morphine equivalent use, duration of hospitalization, and time until return of bowel function was measured. Results: Mean visual analog pain score for a cumulative four day postoperative interval demonstrated 2.2 (± 0.73) for epidural catheter, 3.4 (± 1.13) for patient controlled analgesia (PCA), 3.0 (± 1.42) for intraoperative dexmedetomidine infusion plus PCA, and 2.3 (± 1.09) for perioperative gabapentin, intraoperative dexmedetomidine, combined with PCA. These results achieved statistical significance with p = 0.0443. Total intravenous morphine equivalent use was similar between the three non-epidural groups. There was no difference in length of hospitalization or time until return of bowel function amongst the four groups. Conclusions: Both epidural infusion and a three drug regimen of perioperative gabapentin, intraoperative dexmedetomidine, and PCA produced superior postoperative pain control compared with PCA alone or a combination of PCA and dexmedetomidine. The three drug regimen represents a preferred strategy as it provides optimal pain control without the theoretic risk of epidural hematoma in patients with a predictable postoperative coagulopathy. This pilot study serves as a template for future prospective examination of this three drug regimen versus epidural in major non-hepatic open abdominal surgery where post operative coagulopathy is less of a concern.

A Randomized Comparison of Intraoperative PerfecTemp and Forced-Air Warming During Open Abdominal Surgery

The PerfecTemp is an underbody resistive warming system that combines servocontrolled underbody warming with viscoelastic foam pressure relief. Clinical efficacy of the system has yet to be formally evaluated. We therefore tested the hypothesis that intraoperative distal esophageal (core) temperatures with the PerfecTemp (underbody resistive) warming system are noninferior to upper-body forced-air warming in patients undergoing major open abdominal surgery under general anesthesia. Adults scheduled for elective major open abdominal surgery (liver, pancreas, gynecological, and colorectal surgery) under general anesthesia were enrolled at 2 centers. Patients were randomly assigned to underbody resistive or forced-air warming. Resistive heating started when patients were transferred to the operating room table; forced-air warming started after patients were draped. The primary outcome was noninferiority of intraoperative time-weighted average core temperature, adjusted for baseline characteristics and using a buffer of 0.5°C. Thirty-six patients were randomly assigned to underbody resistive heating and 34 to forced-air warming. Baseline and surgical characteristics were generally similar. We had sufficient evidence (P=0.018) to conclude that underbody resistive warming is not worse than (i.e., noninferior to) upper-body forced-air warming in the time-weighted average intraoperative temperature, with a mean difference of -0.12°C [95% confidence interval (CI) -0.37 to 0.14]. Core temperatures at the end of surgery averaged 36.3°C [95% CI 36 to 36.5] in the resistive warming patients and 36.6°C [95% CI 36.4 to 36.8] in those assigned to forced-air warming for a mean difference of -0.34°C [95% CI -0.69 to 0.01]. Mean intraoperative time-weighted average core temperatures were no different, and significantly noninferior, with underbody resistive heating in comparison with upper-body forced-air warming. Underbody resistive heating may be an alternative to forced-air warming.

Ultrasound-guided bilateral dual transversus abdominis plane block: a new four-point approach

We describe a new ultrasound-guided bilateral dual transversus abdominis plane block. Our hypothesis was that we could anaesthetize both the upper (Th6-Th9) and the lower (Th10-Th12) abdominal wall bilaterally using a four-point single-shot technique to provide effective post-operative analgesia. A prospective cohort of 25 recovery room patients was included. They had undergone major open or laparoscopic abdominal surgery under general anaesthesia and had severe post-operative pain. The blocks were conducted using a high-frequency linear transducer and a 22 G, 80-mm-long needle. The needle was inserted in-plane from medial to lateral for each injection. Fifteen millilitres of bupivacaine 2.5 mg/ml was injected at each of the four sites. Block performance took on average 16 min (range 10-20 min). The 25 patients reported a reduction of their maximum pain (visual analogue scale 0-10) from a mean of 8.2 to a mean of 2.2 10 min after block performance (P<0.001). They were discharged from the post-anaesthesia care unit after an average of 34 min. Twenty-one patients (84%) did not require any i.v. opioids in the following 6 h. Sixteen patients (64%) were mobilized within 6 h after the block. Data were similar irrespective of open or laparoscopic surgery (P=0.68). This new four-point single-shot technique was effective in decreasing severe pain after a major abdominal surgery. The block, although short-lived, facilitated discharge from the post-anaesthesia care unit, few patients required opioids on the day of surgery and mobilization was improved.

A meta-analysis of randomised controlled trials of intravenous fluid therapy in major elective open abdominal surgery: getting the balance right – Corrigendum

A meta-analysis of randomised controlled trials of intravenous fluid therapy in major elective open abdominal surgery: getting the balance right – Corrigendum

A meta-analysis of randomised controlled trials of intravenous fluid therapy in major elective open abdominal surgery: getting the balance right

The terminology used for describing intervention groups in randomised controlled trials (RCT) on the effect of intravenous fluid on outcome in abdominal surgery has been imprecise, and the lack of standardised definitions of the terms 'standard', 'restricted' and 'liberal' has led to some confusion and difficulty in interpreting the literature. The aims of this paper were to clarify these definitions and to use them to perform a meta-analysis of nine RCT on primarily crystalloid-based peri-operative intravenous fluid therapy in 801 patients undergoing elective open abdominal surgery. Patients who received more or less fluids than those who received a 'balanced' amount were considered to be in a state of 'fluid imbalance'. When 'restricted' fluid regimens were compared with 'standard or liberal' fluid regimens, there was no difference in post-operative complication rates (risk ratio 0.83 (95% CI 0.49, 1.39, P = 0.47) [corrected] or length of hospital stay (weighted mean difference (WMD) - 1.77 (95% CI - 4.36, 0.81) d, P = 0.18). However, when the fluid regimens were reclassified and patients were grouped into those who were managed in a state of fluid 'balance' or 'imbalance', the former group had significantly fewer complications (risk ratio 0·59 (95% CI 0·44, 0·81), P=0·0008) and a shorter length of stay (WMD -3·44 (95% CI -6·33, -0·54) d, P=0·02) than the latter. Using imprecise terminology, there was no apparent difference between the effects of fluid-restricted and standard or liberal fluid regimens on outcome in patients undergoing elective open abdominal surgery. However, patients managed in a state of fluid balance fared better than those managed in a state of fluid imbalance.

Association between 5-hydroxytryptamine 2A receptor gene polymorphism and postoperative analgesic requirements after major abdominal surgery

Although the serotonin (5-hydroxytryptamine (5-HT)) 2A receptor has been reported to be associated with pain, no relationship has been found between single nucleotide polymorphisms in the 5-HT2A receptor gene and analgesic requirements. To clarify the mechanism of individual differences in analgesic requirements, we investigated the relationship between the 5-HT2A 102T/C gene polymorphism and analgesic requirements in 135 patients who underwent major open abdominal surgery and were managed with continuous epidural analgesia with opioids after surgery. Genotyping was performed using polymerase chain reaction-restriction fragment length polymorphism. We found that the 102T/C polymorphism had significant main effects with regard to analgesic requirements. In addition, significant interaction effects were found between the 102T/C polymorphism and sex in terms of analgesic requirements. Among female subjects, patients with the T/T genotype of the 102T/C polymorphism had more analgesic requirements than those with the other genotypes. This finding suggests that the linkage disequilibrium block, which includes the 102T/C polymorphism of the 5-HT2A receptor gene, is involved in individual differences in analgesic requirements in women.

Functional intravascular volume deficit in patients before surgery

Stroke volume (SV) maximization with a colloid infusion, referred to as individualized goal-directed therapy, improves outcome in high-risk surgery. The fraction of patients who need intravascular volume to establish a maximal SV has, however, not been evaluated, and there are only limited data on the volume required to establish a maximal SV before the start of surgery. Therefore, we estimated the occurrence and size of the potential functional intravascular volume deficit in surgical patients. Patients scheduled for mastectomy (n=20), open radical prostatectomy (n=20), or open major abdominal surgery (n=20) were anaesthetized, and before the start of surgery, a 200 ml colloid fluid challenge was provided and repeated if a >or=10% increment in SV estimated by oesophageal Doppler was established. The volume needed for SV maximization defined the intravascular volume deficit. Forty-two (70%) of the patients needed volume to establish a maximal SV. For the patients needing volume, the required amount was median 200 ml (range 200-600 ml), with no significant difference between the three groups of patients. The required volume was >or=400 ml in nine patients (15%). The majority of anaesthetized patients present with a functional intravascular volume deficit before surgery. Although the deficit in general was minor, a fraction of patients presented with a deficit that may be of clinical relevance, emphasizing the importance of the individual approach of goal-directed fluid therapy.

Is Transurethral Catheterisation the Ideal Method of Bladder Drainage? A Survey of Patient Satisfaction With Indwelling Transurethral Urinary Catheters

Bladder catheterisation is a routine part of major abdominal surgery. Transurethral catheterisation is the most common method of bladder drainage but is also notorious for its discomfort and increased risk of urinary tract infection. The present study aimed to establish patient satisfaction with transurethral catheterisation and to assess the incidence of clinically significant urinary tract infections after transurethral catheterisation through survey. All patients who underwent major open abdominal surgery between October 2006 and December 2008 and required standard transurethral bladder catheterisation, were asked to participate in the study. Fifty patients were recruited. Male patients were more dissatisfied than their female counterparts with transurethral catheterisation (satisfaction score: 4.18/10 vs. 2.75/10; p = 0.05). Male patients had more than double the score for pain at the urinary meatus with the catheter in situ (p =0.012) and during urine catheter removal (p = 0.013). Half the patients in the study also had symptoms of urinary tract infection after catheter removal. Our study emphasised the discomfort of transurethral urinary catheters, especially in male patients, and the high incidence of urinary tract infections in both sexes. Consideration should be given to the utilisation of alternative methods of bladder drainage, such as suprapubic catheterisation, which can be performed with ease during laparotomy.

Comparison of two ventilatory strategies in elderly patients undergoing major abdominal surgery

'Open lung' ventilation is commonly used in patients with acute lung injury and has been shown to improve intraoperative oxygenation in obese patients undergoing laparoscopic surgery. The feasibility of an 'open lung' ventilatory strategy in elderly patients under general anaesthesia has not previously been assessed. 'Open lung' ventilation (recruitment manoeuvres, tidal volume 6 ml kg(-1) predicted body weight, and 12 cm H(2)O PEEP) (RM group) was compared with conventional ventilation (no recruitment manoeuvres, tidal volume 10 ml kg(-1) predicted body weight, and zero end-expiratory pressure) in elderly patients (>65 yr) undergoing major open abdominal surgery with regard to oxygenation, respiratory system mechanics, and haemodynamic stability. We also monitored the serum levels of the interleukins (IL)-6 and IL-8 before and after surgery to determine whether the systemic inflammatory response to surgery depends on the ventilatory strategy used. Twenty patients were included in each group. The RM group tolerated open lung ventilation without significant haemodynamic instability. Intraoperative Pa(o(2)) improved in the RM group (P<0.01) and deteriorated in controls (P=0.01), but postoperative Pa(o(2)) was similar in both groups. The RM group had improved breathing mechanics as evidenced by increased dynamic compliance (36%) and decreased airway resistance (21%). Both IL-6 and IL-8 significantly increased after surgery, but the magnitude of increase did not differ between the groups. A lung recruitment strategy in elderly patients is well tolerated and improves intraoperative oxygenation and lung mechanics during laparotomy.

A Prospective Randomized Trial Comparing Patient-Controlled Epidural Analgesia to Patient-Controlled Intravenous Analgesia on Postoperative Pain Control and Recovery After Major Open Gynecologic Cancer Surgery

A previous prospective comparative study reported no difference in resting or dynamic pain scores among women with gynecologic cancer undergoing laparotomy and radical hysterectomy who were treated with either local anesthetic/opioid patient-controlled epidural analgesia (PCEA) or conventional intravenous (IV) opioid patient-controlled analgesia (PCA). However, there was a shorter hospital stay, earlier return of bowel function, and use of less morphine in the PCEA group. No prospective randomized trials have compared IV PCA to PCEA for postoperative control of pain in women treated for benign or malignant gynecologic diseases. This prospective randomized study compared the effect of PCEA and IV morphine PCA on pain scores and other postoperative recovery parameters in women undergoing major open abdominal surgery. Between 2004 and 2007, 67 patients were randomized to PCEA (treatment group) and 68 to the IV PCA (control group). The majority of study women (75%) had gynecologic cancer. Pain and other postoperative outcomes were compared with an intention-to-treat analysis. A 10-point visual analog scale (VAS) was used to measure postoperative pain, at rest and when coughing. There was significantly less pain at rest among patients in the PCEA group postoperatively on day 1 compared to the PCA group (mean VAS: 3.3 vs. 4.3, P = 0.01). Superior pain control during coughing was found in the PCEA group for first 3 postoperative days; the mean VAS scores on days 1, 2, and 3 were 5.5, 5.0, and 4.7 in the PCEA group, and 6.7, 6.5, and 5.7 in the PEA group (P < 0.05). During the first 6 days, overall postoperative pain in the PCEA group was significantly lower during both rest and coughing compared to the PCA group (P < 0.003). No significant major adverse events were associated with placement or use of the thoracic epidural, and an extremely low rate of epidural malfunctioning was noted. These data show superior pain control by PCEA in comparison to conventional IV PEA among women undergoing major open abdominal surgery, and are consistent with the findings of other randomized controlled trials in different patient populations.

Association between KCNJ6 (GIRK2) Gene Polymorphisms and Postoperative Analgesic Requirements after Major Abdominal Surgery

Opioids are commonly used as effective analgesics for the treatment of acute and chronic pain. However, considerable individual differences have been widely observed in sensitivity to opioid analgesics. We focused on a G-protein-activated inwardly rectifying potassium (GIRK) channel subunit, GIRK2, that is an important molecule in opioid transmission. In our initial polymorphism search, a total of nine single-nucleotide polymorphisms (SNPs) were identified in the whole exon, 5′-flanking, and exon-intron boundary regions of the KCNJ6 gene encoding GIRK2. Among them, G-1250A and A1032G were selected as representative SNPs for further association studies. In an association study of 129 subjects who underwent major open abdominal surgery, the A/A genotype in the A1032G SNP and -1250G/1032A haplotype were significantly associated with increased postoperative analgesic requirements compared with other genotypes and haplotypes. The total dose (mean±SEM) of rescue analgesics converted to equivalent oral morphine doses was 20.45±9.27 mg, 10.84±2.24 mg, and 13.07±2.39 mg for the A/A, A/G, and G/G genotypes in the A1032G SNP, respectively. Additionally, KCNJ6 gene expression levels in the 1032A/A subjects were significantly decreased compared with the 1032A/G and 1032G/G subjects in a real-time quantitative PCR analysis using human brain tissues, suggesting that the 1032A/A subjects required more analgesics because of lower KCNJ6 gene expression levels and consequently insufficient analgesic effects. The results indicate that the A1032G SNP and G-1250A/A1032G haplotype could serve as markers that predict increased analgesic requirements. Our findings will provide valuable information for achieving satisfactory pain control and open new avenues for personalized pain treatment.

Analgesic Requirements After Major Abdominal Surgery are Associated with OPRM1 Gene Polymorphism Genotype and Haplotype

The association between SNPs of the human OPRM1 gene encoding the micro-opioid receptor and postoperative analgesic requirements in surgical patients remains controversial. Here, we evaluate whether any of the five tag SNPs (A118G, IVS2+G691C, IVS3+G5953A, IVS3+A8449G and TAA+A2109G) representing the four linkage disequilibrium blocks of the OPRM1 gene influences postoperative analgesic requirements. We studied 138 adult Japanese patients who underwent major open abdominal surgery under combined general and epidural anesthesia and received continuous postoperative epidural analgesia with opioids. The 118G homozygous (GG) patients required 24-h postoperative analgesics more than 118A homozygous (AA) and heterozygous (AG) patients. Tag SNP haplotypes also were associated with 24-h postoperative analgesic requirements. These results suggest that OPRM1 gene tag SNP genotypes and haplotypes can primarily contribute to prediction of postoperative analgesic requirements in individual patients undergoing major open abdominal surgery.

Prospective Audit Comparing Intrathecal Analgesia (Incorporating Midazolam) with Epidural and Intravenous Analgesia after Major Open Abdominal Surgery

Potentiation of opioid analgesia can be achieved by the addition of midazolam intrathecally. At our institution, analgesia following open abdominal surgery is provided by continuous infusion of analgesic solutions either intravenously, intrathecally (incorporating midazolam) or epidurally. We report the results of a study comparing outcomes with these three analgesic regimens following major open abdominal surgery. This was an unblinded prospective audit of pain service intervention rates, pain scores and other outcomes after intravenous, intrathecal and epidural analgesia after open abdominal surgery in patients over 60 years of age. Both elective and emergency cases were included over a nine-month period. Patients ventilated for 24 hours or more were excluded. The analgesic regimens were as follows: (1) Intravenous: patient controlled analgesia with morphine+ketamine infusion 0.1 to 0.2 mg/kg/h. (2) Intrathecal: (morphine 10 microg/ml+midazolam 100 microg/ml+bupivacaine 0.05%) commenced at 2 ml/h. (3) Epidural: bupivacaine 0.125% +fentanyl 2 microg/ml at 6 to 14 ml/h. Co-analgesic administration was as per our usual practice but was not standardised. The median number of calls per patient to the pain service differed between the intravenous (1), intrathecal (1) and epidural (3) groups. The number of unintentional analgesic regimen terminations differed between the intravenous (1), intrathecal (1) and epidural (5) groups. Pain scores differed significantly between groups and were lowest in the intrathecal group at all time points. The findings indicate that the intrathecal group had both a low requirement for postoperative interventions/resources and excellent analgesia. It appears to be a suitable alternative to the other techniques.

Which Octogenarians Do Poorly After Major Open Abdominal Surgery in Our Asian Population?

As the elderly population grows and surgeons are faced with more octogenarians, there is a need to know how our Asian patients fair after major surgery. A retrospective review of 125 octogenarians who underwent major abdominal surgery between January 1997 and September 2003 was performed. Preoperative condition was assessed using a weighted index of comorbidity used in Charlson Comorbidity Index and classification of patients according to the American Society of Anaesthesiologists (ASA). Outcome was measured as to whether complications developed, 30-day mortality and whether there was return to premorbid function. The patients had a mean age of 84.6 years (range: 80-106). Nearly half (48.8%, n = 61) the cases were emergency cases. The median index of comorbidity was 3, and 29.6% of patients were classified either ASA III or IV. The operations were mostly stomach, small bowel or large bowel resection. Multivariate analysis revealed that emergency operations were associated with significantly increased odds of morbidity. The overall 30-day mortality was 5.6%, being only 4.7% for elective cases, despite high morbidity rates. ASA classification, comorbidity index >5, development of acute coronary syndrome and anastomotic leakage were found on multivariate analysis to significantly increase the odds of mortality. For elective cases, 82.8% of patients were able to return to their premorbid functional status. Development of complications and comorbidity index >5 were found to predict failure of its occurrence. Low serum albumin and haemoglobin and renal impairment were also predictors of adverse outcome. Efforts to improve outcome in geriatric surgery patients should emphasize a shift of attitude towards elective surgery rather than doing emergency operations when complications occur and also target the optimization of predictors of adverse outcome. Octogenarians should not be denied elective surgery.

Water-filled garment warming of infants undergoing open abdominal or thoracic surgery

We have assessed the efficacy of a water-filled garment (ThermoWrap-Allon 2001) to maintain normothermia in small infants during major open abdominal or thoracic surgery. Twenty-two patients were studied in a case-matched comparison of two methods of thermal control intended to maintain core body temperature at 37 degrees C. The standard method involved a warm air mattress with additional insulation. The ThermoWrap garment covered the head, trunk and legs and the water temperature was automatically controlled. Central and peripheral temperatures were recorded every 15 min. Nineteen infants had abdominal and three had thoracic operations. The mean weight was 3.2 kg (range 1.4-7.8 kg). Over time, the core temperature declined with standard care but not with the ThermoWrap. Core temperature was statistically lower in the standard care infants by 30 min after start of surgery. Six infants had a core temperature of less than 35 degrees C with standard care (lowest 33.7 degrees C); the lowest temperature with the ThermoWrap was 35.6 degrees C. Some infants had cold hands with the ThermoWrap. Core temperature is better preserved with the ThermoWrap; extra insulation of exposed arms may be necessary. An important advantage of the ThermoWrap is its ability to control body temperature automatically.

The Threshold for Thermoregulatory Vasoconstriction during Nitrous Oxide/Isoflurane Anesthesia Is Lower in Elderly Than in Young Patients

Thermoregulatory vasoconstriction minimizes further core hypothermia during anesthesia. Elderly patients become more hypothermic during surgery than do younger patients, and take longer to rewarm postoperatively. These data indicate that perianesthetic thermoregulatory responses may be especially impaired in the elderly. Accordingly, the authors tested the hypothesis that the thermoregulatory threshold for vasoconstriction during nitrous oxide/isoflurane anesthesia is reduced more in elderly than in young patients. The authors studied 12 young patients aged 30-50 yr and 12 elderly patients aged 60-80 yr. All were undergoing major orthopedic or open abdominal surgery. Anesthesia was induced with thiopental and fentanyl, and maintained only with nitrous oxide (70%) and isoflurane (0.6-0.8%). Core temperature was measured in the distal esophagus. Fingertip vasoconstriction was evaluated using forearm minus fingertip, skin-temperature gradients. A gradient of 4 degrees C identified significant vasoconstriction, and the core temperature triggering vasoconstriction identified the thermoregulatory threshold. The vasoconstriction threshold was significantly less in the elderly patients (33.9 +/- 0.6 degree C) than in the younger ones (35.1 +/- 0.3 degrees C) (P < 0.01). The gender distribution, weight, and height of the elderly and young patients did not differ significantly. The end-tidal isoflurane concentration at the time of vasoconstriction did not differ significantly in the two groups. These data indicate that thermoregulatory responses in the elderly are initiated at temperatures approximately 1.2 degrees C less than that in younger patients. Thus, it is likely that elderly surgical patients become more hypothermic than do younger patients, at least in part, because they fail to trigger protective thermoregulatory responses.

Laparoscopic Vagotomy: Gimmick or Reality?

The use of H2 blockers has led to a virtual demise of elective surgery for the treatment of duodenal ulcers. Some ulcers, however, are resistant to medications, and some patients are weary of continuous medication in the long term. Laparoscopic vagotomy is a promising new form of surgical treatment that could offer an alternative to long-term medication and major open abdominal surgery. Prospective well-documented and detailed studies are needed, however, before an objective evaluation of this procedure can be made.