Seventh Postoperative Day Research Articles

P 93 TMS recruitment curve and cortical silent period analysis: a sensitive tool to detect imminent motor deficits in brain tumor patients

Background One of the challenges in surgery of tumors in motor eloquent areas is the individual risk assessment for postoperative motor disorder. Previously, we developed a predictive model that allows for objective evaluation of this risk prior to surgery based on topographical and neurophysiologial data derived from investigation with nTMS (navigated Transcranial Magnetic Stimulation). The input variables of the model are: (1) presence of infiltration of the primary motor cortex by the tumor, (2) the minimal distance of the tumor to the corticalspinal tract and (3) the ratio of the bihemispheric resting motor threshold (RMT). The aim of this study is the improvement of the prognostic power of the aforementioned model by including additional neurophysiological parameters: Recruitment Curve (RC) and Cortical Silent Period (CSP). Methods nTMS was used to map the cortical motor representation area of the FDI muscle in 149 patients with malignant gliomas in presumed motor eloquent areas prior to surgery. In addition to RMT determination, the RC was measured by applying 70 stimuli of randomized intensity between 80% and 150% of the RMT over the FDI hot spot. CSP was determined by applying 10 stimuli of 130% RMT intensity during tonic muscle contraction and measuring the duration of the plateau phase from EMG recording. Each metric was measured bihemispherically. Finally, the ratio between left and right hemisphere is calculated. For definition of a physiologic range, a control group of 17 healthy volunteers was investigated with the same protocol. In order to quantify the motor function we evaluated the muscle strength according to the British Medical Research Council Scale preoperatively and postoperatively after seven days and three months. Results In respect to the postoperative motor outcome after seven days, the RMT Ratio’s predictive value was confirmed (p = 0,036). Yet, in respect to the postoperative motor outcome after three months no significant correlation could be found (p = 0,16). For the CSP Ratio no correlation to the postoperative motor status was observed. A tendency to an increased presurgical cortical GABAergic inhibition in patients with new postoperative deficits was recognizable, but is was significant for neither the seventh postoperative day (p = 0,19) nor after three months (p = 0,75). For the presurgical RC Ratio on the other hand, a significant correlation to the preoperative motor status (p = 0,029) as well as for postoperative deterioration of motor function after three months in patients with cortico-subcortical tumors was found (p = 0,004). Conclusions Addition of the RC Ratio significantly improved the value of the nTMS based predictive model, since the RC Ratio allows for prediction of new motor deficits 3 month after surgery. Addition of the CSP Ratio on the other hand did not, based on the current analysis, add predictive power to the model. The predictive power of the previously established correlation between presurgical RMT Ratio and motor status on day 7 was improved based on the larger study sample. The current results demonstrate that the RC Ratio and the RMT Ratio are sensitive markers to predict the motor outcome 7 days and 3 month after surgery of brain tumors in presumed motor eloquent location and can therefore supply valuable information during preoperative risk-benefit-balancing.

Influence of the postoperative inflammatory response on cognitive decline in elderly patients undergoing on-pump cardiac surgery: a controlled, prospective observational study

BackgroundThe role of non-infective inflammatory response (IR) in the aetiology of postoperative cognitive dysfunction (POCD) is still controversial. The aim of this controlled, prospective observational study was to assess the possible relationship between the grade of IR, defined by procalcitonin (PCT) changes, and development of POCD related to cardiac surgery.MethodsForty-two patients, who were ≥ 60 years of age and scheduled for elective cardiac surgery, were separated into the low inflammatory (LIR) and high inflammatory (HIR) response groups based on their PCT levels measured on the first postoperative day. A matched normative control group of 32 subjects was recruited from primary care practice. The PCT and C-reactive protein (CRP) levels were monitored daily during the first five postoperative days. The cognitive function and mood state were preoperatively tested with a set of five neurocognitive tests and two mood inventories and at the seventh postoperative day. The Reliable Change Index modified for practice (RCIp) using data from normative controls was applied to determine the significant decline in test performance.ResultsThe LIR (n = 20) and HIR (n = 22) groups differed significantly in the PCT (p < 0.001) but not in the CRP time courses. The incidence of POCD at the first postoperative week was 35.7% in the cohort. The LIR and HIR groups did not vary in the RCIp Z scores of neurocognitive tests and frequencies of POCD (7 vs 8 cases, respectively, p > 0.05). Additionally, there was no difference in the mood states, anxiety levels and perioperative parameters known to influence the development of POCD.ConclusionsIn this study, the magnitude of the non-infective inflammatory response generated by on-pump cardiac surgery did not influence the development of POCD in the early postoperative period in elderly patients.

Enhanced survival of ischemic skin flap by combined treatment with bone marrow-derived stem cells and low-level light irradiation.

The aim of this study is to examine the enhanced survival effect of ischemic skin flap by combined treatment with bone marrow-derived stem cells (BMSCs) and low-level light irradiation (LLLI). The neovasculogenic effect of BMSCs induced by LLLI was detected using a wound healing and tube formation assay. ICR mice were divided into four groups: control group, LLLI group, BMSCs group, and combine-treated group. The percentage of skin flap necrosis area was calculated on the seventh post-operative day. Specimens were harvested for histologic analyses. LLLI promoted BMSC migration and tube formation. The flap survival rate of combined treated group was significantly higher than that of the control group. Histologic results demonstrated a significant increase in neovascularization in the combined treatment group. This study demonstrates that combination treatment of BMSCs and LLLI could enhance the survival of ischemic skin flap in a mouse model.

Systemic inflammatory response after hernia repair: a systematic review.

All surgical procedures elicit a complex systemic inflammatory response effectuated and modulated by cytokines. The purpose of this systematic review was to present an overview of the inflammatory response and the serum markers associated with hernia repair and to compare the response between patients treated with and without mesh. The review was conducted in line with PRISMA guidelines. The outcomes of interest were serum concentration of leukocytes, cytokines, and acute phase proteins before and after hernia repair with or without mesh reinforcement. The risk of bias was assessed using the Cochrane ROBINS-I tool for non-randomized studies of intervention. A total of 31 studies were included in the systematic review including 1326 patients with a mean age ranging from 33 to 67years. The studies predominantly included males (95.0% males, 5.0% female) with inguinal hernias (98.5% inguinal hernias, 1.5% incisional hernias). The inflammatory response after hernia repair was characterized by an increase in CRP, IL-6, leukocytes, neutrophils, IL-1, IL-10, fibrinogen, and α1-antitrypsin and a decrease in lymphocytes and albumin within the first 24 postoperative hours. The systemic inflammatory response was normalized before or on the seventh postoperative day. A higher CRP and IL-6 serum concentration was found in patients treated with mesh compared with sutured repairs. Hernia repair elicits a systemic inflammatory response characterized by an increase in CRP, IL-6, leukocytes, neutrophils, IL-1, IL-10, fibrinogen, and α1-antitrypsin and a decrease in lymphocytes and albumin. A higher inflammatory response was found after mesh repair compared with non-mesh repair and after open mesh repair compared with laparoscopic mesh repair.

The Effects of Passive Cigarette Smoke Exposure on the Survival of the Reverse Sural Fasciocutaneous Flap.

Background The possibility of a person who had undergone surgery to be exposed to the ill effects of cigarette smoke is high, more so if the person lives with a smoker. With increasing popularity of reverse sural fasciocutaneous flaps, a surgeon may have to manage a person who lives with a smoker or is exposed to cigarette smoke. A clear understanding of the effects of exposure to cigarette smoke on reverse sural fasciocutaneous flaps is necessary. This study was performed to establish a clearer understanding of the effects of smoking on reverse sural fasciocutaneous flaps and evidence for preoperative patient counseling about smoking and smoke exposure. Objective The study investigated effects of exposure to cigarette smoke on the survival of the reverse sural fasciocutaneous flap. Methods This was an experimental observational study conducted at the Laboratory for Animal Research Unit in the Health Campus of Universiti Sains Malaysia. Twelve adult White New Zealand rabbits ( Oryctolagus cuniculus ) were divided into two groups of six. All 12 rabbits had a 2.5- × 2.5-cm reverse sural fasciocutaneous flap raised on both its hind limbs. The group exposed to cigarette smoke underwent 4 weeks of smoke exposure for 2 hours daily prior to surgery. This was then continued until analysis of the results. The control group had no intervention. All flaps were analyzed on the seventh postoperative day, after tracing on transparent plastic sheets with the necrotic area marked followed by 2D planimetry done on a grid paper. The flaps were assessed on the total flap area and survival area percentage. It was recorded as mean ± SD. The presence or absence of infection and hematoma was also noted. Results Twelve flaps were analyzed in each group. Total mean flap area and survival area percentage of the control group were 120.33 ± 31.03 mm 2 and 80.12 ± 15.75%, respectively, whereas in the cigarette smoke-exposed group, it was 121.83 ± 17.93 mm 2 and 62.04 ± 34.01%, respectively. The control group had two infections and one hematoma, and the smoking-exposed group had six infections and nine hematomas. The comparison between the groups was made in terms of total flap area, survival percentage, presence of infection, and hematoma for which the p values were 0.886, 0.115, 0.083, and 0.003, respectively. The differences between right and left hind limbs were also analyzed ( p = 0.414). Conclusion There was no statistical difference in the results from the right and left hind limbs. There was no statistical difference in the survival of reverse sural fasciocutaneous flap between the control and smoking-exposed groups.

Comparison of clinical outcomes using a Piezosurgery device vs. a conventional osteotome for lateral osteotomy in rhinoplasty.

Our aim for this study was to evaluate and compare the clinical outcomes in patients who underwent lateral osteotomy with a Piezosurgery device or a conventional osteotome in open-technique rhinoplasty. This cohort trial involved 65 patients (36 women and 29 men; average age: 23.6 ± 5.71 yr) who underwent surgery between May 2015 and January 2016. Piezosurgery was used for lateral osteotomy in 32 patients, whereas 33 patients underwent conventional external osteotomy. These 2 groups were compared for duration of surgery, perioperative bleeding, postoperative edema, ecchymosis, pain, and patient satisfaction on the first and seventh postoperative days. The Piezosurgery group revealed significantly more favorable outcomes in terms of edema, ecchymosis, and hemorrhage on the first day postoperatively (p < 0.001 for all). Similarly, edema (p = 0.005) and ecchymosis (p < 0.001) on the seventh postoperative day also were better in the Piezosurgery group. Hemorrhage was similar in both groups on the seventh postoperative day (p = 0.67). The Piezosurgery group not only experienced less pain on the first postoperative day (p < 0.001), but these patients also were more satisfied with their results on both the first and seventh postoperative days. Results of the present study imply that Piezosurgery may be a promising, safe, and effective method for lateral osteotomy, a critical step in rhinoplasty. The time interval necessary for the learning curve is counteracted by the comfort and satisfaction of both patients and surgeons.

RAGE antagonism by FPS‑ZM1 attenuates postoperative cognitive dysfunction through inhibition of neuroinflammation in mice.

Neuroinflammation triggered by surgical trauma contributes to postoperative cognitive dysfunction (POCD). The receptor for advanced glycation end‑products (RAGE), a multiligand inflammatory receptor, is involved in the damaging effects of various cellular processes, contributing to neuroinflammation and neurodegeneration. However, the potential role of RAGE in the acute period of POCD has not been fully investigated. C57BL/6 male mice undergoing surgery of the tibia under isoflurane anesthesia were treated with the RAGE antagonist FPS‑ZM1 or vehicle control intraperitoneally for a period of 7days. The cognitive function of the animals was tested using trace fear conditioning on the third postoperative day. To determine astrocytic activation, microgliosis, p65 expression, inflammatory factor levels and postsynaptic density protein‑95 (PSD‑95) expression in the hippocampus, the animals were euthanized on either the first, third or seventh postoperative day. Compared with the control group, the cognitive function of the surgical animals was impaired on the third postoperative day. Astrocytic activation, microgliosis and the expression levels of p65, interleukin (IL)‑1β, IL‑6, and PSD‑95 were significantly increased on the first, and third postoperative days. However, tumor necrosis factor‑α expression was significantly increased only on postoperative day1. All of the surgical effects observed were partially inhibited by treatment with FPS‑ZM1. In summary, the results of the present study suggest that RAGE serves an important role in the acute inflammatory process of POCD, and blocking RAGE can inhibit neuroinflammation and attenuate POCD. Thus, the RAGE signaling pathway may be a novel target in the prevention, and treatment of POCD.

Back-Table Surgeon Modification of a t-Branch

Surgeon modification of commercially available aortic stent grafts represents a salvage option to treat complex aortic pathologies in high-risk patients. A 68-year-old male was referred to our hospital with a contained rupture of the visceral aorta. The patient was previously treated with an infrarenal tube graft 16years earlier as well as with a Crawford procedure with island patch of the celiac trunk (TC) and the superior mesenteric artery (SMA) and bypasses to both renal arteries 6years before admission. The computed tomography demonstrated a "blowout aneurysm" of the TC and SMA patch. The bypass to the left renal artery originated from the level of the TC. We therefore modified a commercially available t-branch (Cook® Medical, Bloomington, IN) with surgeon-made fenestrations for both renal arteries. The procedure was successful, and the patient could be discharged to home on the seventh postoperative day. The use of surgeon-modified "off-the-shelf" t-branches broadens the possibilities of treating even anatomically very challenging aortic pathologies otherwise not suitable for the t-branch.

A robotic needle driver to facilitate vescico-urethral anastomosis during laparoscopic radical prostatectomy.

The completion of the vescico-urethral anastomosis (VUA) represents the most critical step of laparoscopic radical prostatectomy (LRP), and it can often discourage the use of minimally invasive surgery in less experienced laparoscopic surgeons. The aim of this paper is to evaluate the usefulness of a new robotic needle driver named Dextérité in performing the VUA after LRP. This prospective randomized clinical study enrolled 40 consecutive patients eligible for LRP, which were randomized into four groups: group A, patients undergoing LRP done by an expert surgeon; group B, patients undergoing robotic-assisted radical prostatectomy (RARP) performed by the same expert surgeon; group C, patients undergoing LRP performed by a young surgeon at the beginning of the learning curve; group D, patients undergoing LRP performed by another young surgeon at the beginning of the learning curve with the aid of Dextérité needle driver for completion of the VUA. The two young urologists performed the same steps of LRP so that they are at the same step of the learning curve. All the anastomosis were performed with the same technique in order to be comparable. We use interrupted sutures with Vicryl 2/0 and a 5/8 needle; we performed the Rocco stitch technique before all the anastomosis (6) and we applied bladder neck sparing technique. All patients underwent an ultrasound control of the anastomosis on the seventh postoperative day, as we usually do (9, 10). We consider continent who utilised no pad. Operative VUA completion time was 24.9 vs. 25 vs. 86.7 vs. 61 minutes, respectively. When comparing VUA completion time in group 3 and 4, the use of the Dextérité needle driver resulted in a reduction in VUA time. Urinary leakage was seen in zero out of 10 patients in groups 1 and 2 and in three out of 10 and one in 10 patients, respectively, in groups 3 and 4. All urinary leakages were managed conservatively. One-year continence rates were 95%, 97%, 93% and 95%, respectively. Only one patient in group C developed a bladder neck contracture 6 months after the procedure, but he underwent adiuvant radiotherapy after surgery. Our data suggest that the use of Dextérité needle holder significantly reduces operative time of VUA completion and reduces the incidence of urinary leakage in laparoscopic surgeons at the beginning of the learning curve.

Listeria monocytogenes Brain Abscess within a Metastatic Intracerebellar Space-Occupying Lesion in a Patient with Carcinoma Lung: First Case Report from India

Abstract Listeria monocytogenes infections are rare. Neonates and geriatric population, pregnant women, and diabetic and immunocompromised patients are at higher risk for invasive listeriosis. Early recognition of Listeria brain abscess remains a major challenge. Here, we describe a case of intratumoral abscess with L. monocytogenes in a patient with intracerebellar metastasis from poorly differentiated adenocarcinoma lung. Right cerebellar tumor with a thick-walled purulent cavity was resected. Histopathologic examination revealed acute inflammation consistent with abscess and showed metastatic poorly differentiated adenocarcinoma. Cultures of the abscess fluid grew L. monocytogenes. She responded well to ampicillin-gentamycin therapy and the surveillance imaging done on the seventh postoperative day showed clearance of the abscess. The patient is further being planned for radiotherapy in regard to metastasis. Listeria abscess within a metastatic tumor is very rare and only one case is reported as of our knowledge. Listeria abscess being reported within an intracerebellar metastatic space-occupying lesion is for the first time.

Evaluation of the Need for Antibiotic Prophylaxis During Routine Intra-alveolar Dental Extractions in Healthy Patients: A Randomized Double-Blind Controlled Trial

ObjectiveThe aim of this randomized double-blind controlled trial was to evaluate the role of antibiotics in the perioperative period of dental extractions in healthy patients. MethodsThe study population included patients visiting the outpatient department of our institute. Four hundred patients were selected and randomly divided into 4 groups and underwent routine dental extraction. In group A, patients were prescribed only anti-inflammatory drugs in the postoperative period. In group B, patients were prescribed antibiotics for 3 days and concomitant anti-inflammatory drugs in the postoperative period only. In group C, patients were prescribed a single dose of antibiotic 1 hour before the extraction procedure with no postoperative antibiotics, and only anti-inflammatory drugs were prescribed in the postoperative period. In group D, patients were prescribed mouthwash starting 15 minutes before the procedure and continuing twice daily for a period of 7 days along with anti-inflammatory drugs in the postoperative period. Patients were asked to follow up on the seventh postoperative day for suture removal and were evaluated for pain, swelling, dry socket, and local signs of infection. The study was approved by the Internal Ethics Review Committee of the institute. ResultsNo significant differences were seen among the groups with respect to pain (χ2 [1, N = 171] = 4.939, P = .552), swelling (χ2 [1, N = 171] = 10.048, P = .347), or postextraction complications. ConclusionsProphylactic antibiotics are not required during routine dental extractions in healthy patients. The use of antibiotic therapy without appropriate indications can result in the development of resistant organisms. However, a clear trend is seen in which practitioners overprescribe antibiotics as well as medications in general. The current evidence questions the benefits of prophylactic antibiotic therapy for patients undergoing dental extractions. In our opinion, there is no justification for routine antibiotic prophylaxis for dental extractions in healthy patients.

Effects of teduglutide on histological parameters of intestinal anastomotic healing

Intestinal anastomotic failure continues to be one of the most relevant surgical incidents. Teduglutide is an enterotrophic long-acting equivalent of glucagon-like peptide-2 (GLP-2) recommended for the treatment of adult patients with short bowel syndrome. This study evaluates the effects of short-term teduglutide administration on histological parameters of intestinal anastomotic healing in an animal model. Wistar rats (n = 31) were submitted to ileal resection and standard anastomosis, with or without postoperative teduglutide ministration, and sacrificed at the third or seventh day with tissue and blood sampling. Intestinal anastomotic healing was assessed with the modified Houdart–Hutschenreiter classification after hematoxylin and eosin staining. Collagen content and distribution were evaluated with the Gordon and Sweet technique; neoangiogenesis and epithelial proliferation indexes with anti-CD31 and anti-Ki67 immunostaining, respectively. GLP-2 plasma levels were determined by quantitative enzyme immunoassay. Teduglutide administration was associated with higher levels of reepithelialization (P = 0.022) and a higher neoangiogenesis index (neovessel density = 16.0 ± 10.8/mm2 vs. 5.3 ± 3.4/mm2; P = 0.0001) at the seventh postoperative day. Lower expression of type I collagen (P = 0.015) and higher content of type III collagen (P = 0.007) in the submucosa were also documented at the seventh day in teduglutide-treated animals. Drug administration was not associated with statistically significant differences of GLP-2 plasma levels. These findings indicate a positive impact of teduglutide on the reepithelialization and neoangiogenesis events of the proliferative phase of intestinal anastomotic repair. Additional studies are necessary to clarify its effects on the fibrogenesis process.

Postoperative Kinetics of C-Reactive Protein and Erythrocyte Sediment Rate in One-, Two-, and Multilevel Posterior Spinal Decompressions and Instrumentations

Study design:Prospective study.Objective:To characterize the normal pattern of kinetics of postoperative C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) after decompression, spinal instrumentation, and posterolateral fusion in 1, 2, and more than 2 levels.Methods:Blood specimens were obtained from patients who underwent posterior decompression, instrumentation with pedicular screws, and posterolateral fusion from June 2009 to January 2011. CRP and ESR levels were measured on the day before surgery and on postoperative days 1, 3, 7, 11, 14, 28, and 42.Results:Mean CRP levels peaked on the third day postoperatively in all groups. By day 7 postoperatively, it had dropped rapidly. At the 14th and 28th postoperative days, decreases to normal CRP levels were found in 16% and 80% of all patients, respectively. The pattern of decline in CRP was similar among groups. Values of ESR increased and peaked between the third and seventh postoperative days. ESR values gradually decreased. At the 42 day postoperatively, ESR level still remain above normal values in all groups.Conclusions:We compared conventional operation groups of 1-, 2-, and more than 2-level posterior instrumentation and found no statistically significant differences in the peak of CRP level, the ESR value, and the pattern of decline. CRP levels of 80% of the patients returned to normal within 4 weeks.

Analgesia and side effects of the addition of 10 or 20µg fentanyl to articaine in spinal anesthesia for knee arthroscopy: a randomized and observer-blinded study.

Articaine, a popular and rapidly acting local anesthetic in dentistry, has been also found to be beneficial in ambulatory spinal anesthesia. Analgesia in the intraoperative and immediate postoperative period may be further improved by adding fentanyl to the local anesthetic solution for spinal anesthesia. The aim was to evaluate dose-dependency of analgesia and side effects associated with intrathecal fentanyl additive to articaine for spinal anesthesia in knee arthroscopy patients. In this randomized, observer- and patient-blinded study, 90 adult patients scheduled for elective ambulatory knee arthroscopy under spinal anesthesia were randomized into three groups: plain articaine 60mg with saline (group AF0), articaine 60mg with fentanyl 10µg (group AF10) or 20µg (group AF20) in a total volume of 1.9ml. The blinded observer tested the sensory and the motor block, and performed telephone interviews on the first and seventh postoperative days. The median (IQR) duration of sensory block at the dermatomal level of T10 was significantly longer in groups AF10, 69min (56) and AF20, 69min (45) than in group AF0, 41min (35) (p=0.013). Motor block duration was similar in all groups (median 120min). Group AF20 patients experienced pruritus significantly more often than patients in the other groups (p=0.039). No acute or late anesthetic side effects occurred, and satisfaction with the anesthetic technique was the same in all groups (97% satisfied). Fentanyl 10 or 20µg as additive to articaine for spinal anesthesia prolonged the duration of sensory block significantly and similarly. Fentanyl 20µg was more often associated with pruritus than fentanyl 10µg.

Clinical Prediction Model and Tool for Assessing Risk of Persistent Pain After Breast Cancer Surgery.

Purpose Persistent pain after breast cancer surgery is a well-recognized problem, with moderate to severe pain affecting 15% to 20% of women at 1 year from surgery. Several risk factors for persistent pain have been recognized, but tools to identify high-risk patients and preventive interventions are missing. The aim was to develop a clinically applicable risk prediction tool. Methods The prediction models were developed and tested using three prospective data sets from Finland (n = 860), Denmark (n = 453), and Scotland (n = 231). Prediction models for persistent pain of moderate to severe intensity at 1 year postoperatively were developed by logistic regression analyses in the Finnish patient cohort. The models were tested in two independent cohorts from Denmark and Scotland by assessing the areas under the receiver operating characteristics curves (ROC-AUCs). The outcome variable was moderate to severe persistent pain at 1 year from surgery in the Finnish and Danish cohorts and at 9 months in the Scottish cohort. Results Moderate to severe persistent pain occurred in 13.5%, 13.9%, and 20.3% of the patients in the three studies, respectively. Preoperative pain in the operative area ( P < .001), high body mass index ( P = .039), axillary lymph node dissection ( P = .008), and more severe acute postoperative pain intensity at the seventh postoperative day ( P = .003) predicted persistent pain in the final prediction model, which performed well in the Danish (ROC-AUC, 0.739) and Scottish (ROC-AUC, 0.740) cohorts. At the 20% risk level, the model had 32.8% and 47.4% sensitivity and 94.4% and 82.4% specificity in the Danish and Scottish cohorts, respectively. Conclusion Our validated prediction models and an online risk calculator provide clinicians and researchers with a simple tool to screen for patients at high risk of developing persistent pain after breast cancer surgery.

Pericardial Effusion Can Be a Critical Complication After Laparoscopic Hernia Repair Using Mesh and Stapler for Morgagni Hernia

Several cases of Morgagni hernia have recently been treated with laparoscopic mesh repair, which is reported to have fewer complications and to be less invasive. Here we describe a case of a laparoscopic Morgagni hernia repair treated with mesh that progressed to heart failure due to pericardial effusion 2 months after hospital discharge. A 78-year-old woman was incidentally found to have a Morgagni hernia during a routine chest X-ray. The laparoscopic Morgagni hernia repair was performed using Composix mesh and an ENDOPATH EMS stapler. The Composix mesh was gently attached to the surface of the diaphragm using the ENDOPATH EMS stapler. She was discharged from the hospital on the seventh postoperative day without any adverse events. However, 2 months later, she developed dyspnea due to heart failure secondary to a pericardial effusion. Pericardial drainage was performed during her hospitalization, and she was discharged 7 days later. No recurrence of either the pericardial effusion or the Morgagni hernia has been detected since the pericardial drainage. Clinicians may need to be aware of the risk of pericardial effusion in these cases, even if there has been no damage to the diaphragm or epicardium.

Outpatient unicompartmental knee arthroplasty: who is afraid of outpatient surgery?

PurposeIn recent years, duration of hospitalisation after knee arthroplasty has decreased and fast track and outpatient surgery protocols have been developed. Studies have shown that outpatient surgery is feasible, safe, and cost effective. However, the psychological well-being of patients undergoing outpatient surgery has never been described before. The purpose of this study was to investigate how patients experience outpatient surgery for unicompartmental knee arthroplasty (UKA), examining levels of anxiety and depression, satisfaction, and pain. It was hypothesized that the same-day discharge following UKA would not result in higher levels of anxiety and depression, compared to the standard fast-track surgery.MethodsThis case-controlled study included 20 patients undergoing UKA in an outpatient surgery setting and 20 patients undergoing the standard fast-track procedure. The Hospital Anxiety and Depression Scale (HADS, 0–42, lower is better) and numeric rating scales (NRS, 0–10) for pain and satisfaction were collected preoperatively, on the day of surgery, on the first, second, and seventh postoperative days and after 6 and 12 weeks. The Oxford Knee Score (OKS), the KOOS, EuroQoL-5D, and Net Promoter Score (NPS) were collected preoperatively and 3 months postoperatively.Results90% of patients in the outpatient surgery group were discharged on the day of surgery. At the first postoperative day, the median HADS score was significantly lower in the outpatient surgery group compared to the fast-track group (3 vs. 8, p = 0.02), the median NRS satisfaction score was significantly higher in the outpatient surgery group (8 vs. 5, p = 0.03), and no differences existed between both groups for the NRS pain scores. At 3 month follow-up, no significant differences in improvement scores existed between both groups for the HADS, the NRS scores, and for the OKS, KOOS, EuroQoL-5D, and NPS.ConclusionThe results of this study emphasize the feasibility of an outpatient surgery pathway in carefully selected UKA patients. The outpatient surgery pathway is safe, and clinical outcome, including levels of anxiety and depression, satisfaction, and pain, was similar in outpatient surgery patients compared to the standard fast-track patients.Level of evidenceCase-control study, Level III.

Effects of Thyroid Hormone Therapy on Cut-Surface Healing of the Remnant Stomach with Short-Term Weight Loss Alterations after Sleeve Gastrectomy

ABSTRACTBackground: The hypothalamic–pituitary–tyhroid axis is directly affected by drastic changes in energy stores. The aim of the present study was to determine the effects of triiodothyronine (T3) treatment on cut-surface healing of remnant stomach with weight loss alterations after sleeve gastrectomy (SG). Methods: Thirty male Wistar Albino rats were divided into three groups: sham (n = 6), control (n = 12), and experimental (n = 12). Control and experimental group rats underwent sleeve gastrectomy. Experimental group rats received a single dose of T3 (400 mg/100 g) on the first postoperative day whereas control group rats received 0.9% NaCl. All rats were sacrificed on the seventh postoperative day. Results: In the group of rats receiving T3, levels of FT3 were significantly higher and that of FT4 were significantly lower compared with both the control and sham group rats (p <.05). No significant difference was found between control and T3 group rats in terms of weight loss (p >.05). Microscopic examination of the cut surface of remnant stomach in the control group rats revealed significantly more severe tissue necrosis, edema, and disruption of mucosal epithelium than in the T3 group rats (p <.05). On the other hand, bridging of the submucosal and muscular layers, tissue granulation, fibroblast accumulation, neoangiogenesis, and collagen deposition in the T3 group rats were significantly higher than in the control group rats (p <.05). Conclusions: Sleeve gastrectomy did not significantly alter thyroid hormone levels in short term. T3 hormone therapy seems to deliver constructive therapeutic effects for wound healing while causing no adverse effect on weight reduction.

Comparative Columellar Scar Analysis Between W Incisions and Inverted-V Incision in Open Technique Nasal Surgery.

A visible scar on the columella is undesirable result for both patient and surgeon. So it is one of the major disadvantage of open nose surgery. Different columellar incision types have been used in open technique of nasal surgery. In this prospective study, we compare W incisions and inverted-V columellar incisions with a scar assessment scale. In this prospective randomized study, open nasal surgery (open rhinoplasty and open technique septoplasty) were performed on 93 patients between November 2009 and July 2012. The inverted-V incision was used on 31 patients (24 males, 7 females). The "W" incision was used on 62 patients (40 males, 22 females). The entire surgical procedure was performed by a single surgeon. The columellar incision was closed using 6-0 interrupted polypropylene sutures. All sutures were removed on the seventh postoperative day. Scars were assessed at 6 moths, with 3 items scar assessment scale, we observed satisfactory scar, pigmentation, and notching. We compared both groups and found that the scar pigmentation, notching and scar formation are similar to each other. As a result of this study we concluded that the inverted-V incision or "W" incision might be a similar choice in open nasal surgery.

Pulsed Electromagnetic Fields for Postsurgical Pain Management in Women Undergoing Cesarean Section: A Randomized, Double-Blind, Placebo-controlled Trial.

To evaluate the efficacy of pulsed electromagnetic field (PEMF) in relation to reducing postoperative pain, analgesic use, and wound healing in patients undergoing Cesarean section (C-section). This randomized, double-blind, placebo-controlled trial evaluated 72 women who underwent elective C-section. Thirty-six patients were assigned to the active-PEMF and 36 to the sham-PEMF groups. The participants were asked to report their pain intensity on a Visual Analog Scale (VAS) at 2, 4, 6, 12, and 24 hours and 2, 4, and 7 days after surgery. The amount of analgesics used was recorded. The surgical site was evaluated to assess the wound-healing process on the seventh postoperative day. Postoperative pain VAS scores were significantly lower in the active-PEMF group in all the measured periods within the early and the late postoperative periods. Fewer women in the active-PEMF group experienced severe postoperative pain within 24 hours postoperatively (36% vs. 72%, P=0.002). Analgesic use during the first 24 hours after C-section was 1.9-times lower in the active-PEMF group (1.6±0.7 vs. 3.1±1.2, P<0.001). The total analgesic use during the seventh postoperative days was 2.1-times lower in the active-PEMF group than in the sham group (1.7±0.7 vs. 3.7±1.1, P<0.001). Seven days postoperatively, patients in the active-PEMF group had better wound healing with no exudate, erythema, or edema (P=0.02). PEMF treatment after C-section decreases postsurgical pain, analgesic use, and surgical wound exudate and edema significantly, and is associated with a high level of patient satisfaction.