Perioperative nutrition is still a surgical orphan: results of a Swiss-Austrian survey.

Background/Objectives:There is strong evidence for the beneficial effects of perioperative nutrition in patients undergoing major surgery. We aimed to evaluate implementation of current guidelines in Switzerland and Austria.Subjects/Methods:A survey was conducted in 173 Swiss and Austrian surgical departments. We inquired about nutritional screening, perioperative nutrition and estimated clinical significance.Results:The overall response rate was 55%, having 69% (54/78) responders in Switzerland and 44% (42/95) in Austria. Most centres were aware of reduced complications (80%) and shorter hospital stay (59%). However, only 20% of them implemented routine nutritional screening. Non-compliance was because of financial (49%) and logistic restrictions (33%). Screening was mainly performed in the outpatient's clinic (52%) or during admission (54%). The nutritional risk score was applied by 14% only; instead, various clinical (78%) and laboratory parameters (56%) were used. Indication for perioperative nutrition was based on preoperative screening in 49%. Although 23% used preoperative nutrition, 68% applied nutritional support pre- and postoperatively. Preoperative nutritional treatment ranged from 3 days (33%), to 5 (31%) and even 7 days (20%).Conclusions:Although malnutrition is a well-recognised risk factor for poor post-operative outcome, surgeons remain reluctant to implement routine screening and nutritional support according to evidence-based guidelines.

Gerdy tubercle osteotomy in surgical approach of posterolateral corner of the knee.

Posterolateral corner (PLC) injuries of the knee are uncommon injury patterns that may result in significant degrees of functional disability. When surgery is necessary to address this injury a good knowledge of anatomy and a good surgical exposure is the mainstay. This report reviews the complex anatomy of the posterolateral corner (PLC) of knee and describes the osteotomy of Gerdy tubercle as a technical variant to approach this anatomical region. This surgical step allowing a good mobilisation of the multiple layers of ilio-tibial tract from distal to proximal makes an excellent exposure of the PLC structures with absence of morbidity.

Active mitral ring for post-surgical remote correction of residual mitral regurgitation on the beating heart.

OBJECTIVES: Residual mitral regurgitation after valve repair worsens patients' clinical outcome. Postimplant adjustable mitral rings potentially address this issue, allowing the reshaping of the annulus on the beating heart under echocardiography control. We developed an original mitral ring allowing valve geometry remodelling after the implantation and designed an animal study to assess device effectiveness in correcting residual mitral regurgitation. METHODS: The device consists of two concentric rings: one internal and flexible, sutured to the mitral annulus and a second external and rigid. A third conic element slides between the two rings, modifying the shape of the flexible ring. This sliding element is remotely activated with a rotating tool. Animal model: in adult swine, under cardio pulmonary bypass and cardiac arrest, we shortened the primary chordae of P2 segment to reproduce Type III regurgitation and implanted the active ring. We used intracardiac ultrasound to assess mitral regurgitation and the efficacy of the active ring to correct it. RESULTS: Severe mitral regurgitation (3+ and 4+) was induced in eight animals, 54 ± 6 kg in weight. Vena contracta width decreased from 0.8 ± 0.2 to 0.1 cm; proximal isovelocity surface area radius decreased from 0.8 ± 0.2 to 0.1 cm and effective regurgitant orifice area decreased from 0.50 ± 0.1 to 0.1 ± 0.1 cm(2). Six animals had a reversal of systolic pulmonary flow that normalized following the activation of the device. All corrections were reversible. CONCLUSIONS: Postimplant adjustable mitral ring corrects severe mitral regurgitation through the reversible modification of the annulus geometry on the beating heart. It addresses the frequent and morbid issue of recurrent mitral valve regurgitation.

Early vitamin K deficiency bleeding after maternal phenobarbital intake: management of massive intracranial haemorrhage by minimal surgical intervention.

Vitamin K deficiency bleeding within the first 24 h of life is caused in most cases by maternal drug intake (e.g. coumarins, anticonvulsants, tuberculostatics) during pregnancy. Haemorrhage is often life-threatening and usually not prevented by vitamin K prophylaxis at birth. We report a case of severe intracranial bleeding at birth secondary to phenobarbital-induced vitamin K deficiency and traumatic delivery. Burr hole trepanations of the skull were performed and the subdural haematoma was evacuated. Despite the severe prognosis, the infant showed an unexpected good recovery. At the age of 3 years, neurological examinations were normal as was the EEG at the age of 9 months. CT showed close to normal intracranial structures. CONCLUSION: This case report stresses the importance of antenatal vitamin K prophylaxis and the consideration of a primary Caesarean section in maternal vitamin K deficiency states and demonstrates the successful management of massive subdural haemorrhage by a limited surgical approach.

Hypertension and intra-operative incidents: a multicentre study of 125,000 surgical procedures in Swiss hospitals.

It is debated whether chronic hypertension increases the risk of cardiovascular incidents during anaesthesia. We studied all elective surgical operations performed in adults under general or regional anaesthesia between 2000 and 2004, in 24 hospitals collecting computerised clinical data on all anaesthetics since 1996. The focus was on cardiovascular incidents, though other anaesthesia-related incidents were also evaluated. Among 124,939 interventions, 27,881 (22%) were performed in hypertensive patients. At least one cardiovascular incident occurred in 7549 interventions (6% (95% CI 5.9-6.2%)). The average adjusted odds ratio of cardiovascular risk for chronic hypertension was 1.38 (95% CI 1.27-1.49). However, across hospitals, adjusted odd ratios varied from 0.41 up to 2.25. Hypertension did not increase the risk of other incidents. Hypertensive patients are still at risk of intra-operative cardiovascular incidents, while risk heterogeneity across hospitals, despite taking account of casemix and hospital characteristics, suggests variations in anaesthetic practices.

Neuropathy after herniorrhaphy: indication for surgical treatment and outcome.

BACKGROUND: Chronic neuropathy after hernia repair is a neglected problem as very few patients are referred for surgical treatment. The aim of the present study was to assess the outcome of standardized surgical revision for neuropathic pain after hernia repair. METHODS: In a prospective cohort study we evaluated all patients admitted to our tertiary referral center for surgical treatment of persistent neuropathic pain after primary herniorrhaphy between 2001 and 2006. Diagnosis of neuropathic pain was based on clinical findings and a positive Tinel's sign. Postoperative pain was evaluated by a visual analogue scale (VAS) and a pain questionnaire up to 12 months after revision surgery. RESULTS: Forty-three consecutive patients (39 male, median age 35 years) underwent surgical revision, mesh removal, and radical neurectomy. The median operative time was 58 min (range: 45-95 min). Histological examination revealed nerve entrapment, complete transection, or traumatic neuroma in all patients. The ilioinguinal nerve was affected in 35 patients (81%); the iliohypogastric nerve, in 10 patients (23%). Overall pain (median VAS) decreased permanently after surgery within a follow-up period of 12 months (preoperative 74 [range: 53-87] months versus 0 [range: 0-34] months; p<0.0001). CONCLUSIONS: The results of this cohort study suggest that surgical mesh removal with ilioinguinal and iliohypogastric neurectomy is a successful treatment in patients with neuropathic pain after hernia repair.

Improved surgical technique for laparoscopic Roux-en-Y gastric bypass reduces complications at the gastrojejunostomy.

Roux-en-Y gastric bypass (RYGBP) is one of the most commonly performed bariatric procedures for morbidly obese patients. It is associated with effective long-term weight loss, but can lead to significant complications, especially at the gastrojejunostomy (GJS). All the patients undergoing laparoscopic RYGBP at one of our two institutions were included in this study. The prospectively collected data were reviewed retrospectively for the purpose of this study, in which we compared two different techniques for the construction of the GJS and their effects on the incidence of complications. In group A, anastomosis was performed on the posterior aspect of the gastric pouch. In group B, it was performed across the staple line used to form the gastric pouch. A 21-mm circular stapler was used in all patients. A total of 1,128 patients were included between June 1999 and September 2009-639 in group A and 488 in group B. Sixty patients developed a total of 65 complications at the GJS, with 14 (1.2%) leaks, 42 (3.7%) strictures, and 9 (0.8%) marginal ulcers. Leaks (0.2% versus 2%, p = 0.005) and strictures (0.8% versus 5.9%, p < 0.0001) were significantly fewer in group B than in group A. Improved surgical technique, as we propose, with the GJS across the staple line used to form the gastric pouch, significantly reduces the rate of anastomotic complications at the GJS. A circular 21-mm stapler can be used with a low complication rate, and especially a low stricture rate. Additional methods to limit complications at the GJS are probably not routinely warranted.

Laparoscope use and surgical site infections in digestive surgery.

OBJECTIVE: To compare surgical site infection (SSI) rates in open or laparoscopic appendectomy, cholecystectomy, and colon surgery. To investigate the effect of laparoscopy on SSI in these interventions. BACKGROUND: Lower rates of SSI have been reported among various advantages associated with laparoscopy when compared with open surgery, particularly in cholecystectomy. However, biases such as the lack of postdischarge follow-up and confounding factors might have contributed to the observed differences between the 2 techniques. METHODS: This observational study was based on prospectively collected data from an SSI surveillance program in 8 Swiss hospitals between March 1998 and December 2004, including a standardized postdischarge follow-up. SSI rates were compared between laparoscopic and open interventions. Factors associated with SSI were identified by using logistic regression models to adjust for potential confounding factors. RESULTS: SSI rates in laparoscopic and open interventions were respectively 59/1051 (5.6%) versus 117/1417 (8.3%) in appendectomy (P = 0.01), 46/2606 (1.7%) versus 35/444 (7.9%) in cholecystectomy (P < 0.0001), and 35/311 (11.3%) versus 400/1781 (22.5%) in colon surgery (P < 0.0001). After adjustment, laparoscopic interventions were associated with a decreased risk for SSI: OR = 0.61 (95% CI 0.43-0.87) in appendectomy, 0.27 (0.16-0.43) in cholecystectomy, and 0.43 (0.29-0.63) in colon surgery. The observed effect of laparoscopic techniques was due to a reduction in the rates of incisional infections, rather than in those of organ/space infections. CONCLUSION: When feasible, a laparoscopic approach should be preferred over open surgery to lower the risks of SSI.

Cardiopulmonary support and extracorporeal membrane oxygenation for cardiac assist.

BACKGROUND: Use of cardiopulmonary bypass for emergency resuscitation is not new. In fact, John Gibbon proposed this concept for the treatment of severe pulmonary embolism in 1937. Significant progress has been made since, and two main concepts for cardiac assist based on cardiopulmonary bypass have emerged: cardiopulmonary support (CPS) and extracorporeal membrane oxygenation (ECMO). The objective of this review is to summarize the state of the art in these two technologies. METHODS: Configuration of CPS is now fairly standard. A mobile cart with relatively large wheels allowing for easy transportation carries a centrifugal pump, a back-up battery with a charger, an oxygen cylinder, and a small heating system. Percutaneous cannulation, pump-driven venous return, rapid availability, and transportability are the main characteristics of a CPS system. Cardiocirculatory arrest is a major predictor of mortality despite the use of CPS. In contrast, CPS appears to be a powerful tool for patients in cardiogenic shock before cardiocirculatory arrest, requiring some type of therapeutic procedures, especially repair of anatomically correctable problems or bridging to other mechanical circulatory support systems such as ventricular assist devices. CPS is in general not suitable for long-term applications because of the small-bore cannulas, resulting in significant pressure gradients and eventually hemolysis. RESULTS: In contrast, ECMO can be designed for longer-term circulatory support. This requires large-bore cannulas and specifically designed oxygenators. The latter are either plasma leakage resistent (true membranes) or relatively thrombo-resistant (heparin coated). Both technologies require oxygenator changeovers although the main reason for this is different (clotting for the former, plasma leakage for the latter). Likewise, the tubing within a roller pump has to be displaced and centrifugal pump heads have to be replaced over time. ECMO is certainly the first choice for a circulatory support system in the neonatal and pediatric age groups, where the other assist systems are too bulky. ECMO is also indicated for patients improving on CPS. Septic conditions are, in general, considered as contraindications for ECMO. CONCLUSIONS: Ease of availability and moderate cost of cardiopulmonary bypass-based cardiac support technologies have to be balanced against the significant immobilization of human resources, which is required to make them successful.

Surgical treatment of ingrown toenail without matricectomy.

BACKGROUND: Partial excision of the nail matrix (matricectomy) is generally considered necessary in the surgical treatment of ingrown toenail. Recurrences may occur, however, and poor cosmetic results are frequently observed. OBJECTIVE: The objective is to present a new surgical procedure for ingrown toenail with complete preservation of the nail matrix. METHODS: Twenty-three patients with ingrown toenail were included in this study. The surgical excision was performed 1 week after the completion of treatment of the initial infection. A large volume of soft tissue surrounding the nail plate was removed under local anesthesia. No matrix excision was performed. RESULTS: Short-term results were excellent. No recurrences or severe complications were observed during the minimum 12-months follow-up period. Cosmetic results were remarkable. CONCLUSIONS: Ingrown toenail results from the compression of the lateral nail folds on the nail plate. This study shows that ingrown toenail can be surgically treated without matricectomy. A large volume of soft tissue surrounding the nail plate should be removed to decompress the nail and reduce inflammation. Cosmetic results are excellent and superior to the classical Emmert plasty. Postoperative nail dystrophies and spicule formation are not observed. The main advantage of this surgical approach is the complete preservation of the anatomy and function of the nail to improve both therapeutic and cosmetic results.

Traitement non chirurgical des rectites postactiniques ou radiques chroniques [Non-surgical treatment of acute and late radiation proctitis]

Pelvic external radiotherapy with or without brachytherapy plays an important role in the management of pelvic cancers. Despite recent technical innovations including conformal three-dimensional (3D) external beam radiotherapy and more recently intensity modulated radiotherapy (IMRT), local side effects can occur secondary to normal tissue damage caused by ionising radiation. Morbidity depends on the anatomic position of the rectum within the pelvis and the fast turnover rate of the mucosa, as well as the characteristics of the radiation treatment and patient co-morbidities. Medical management is sometimes complex and merits herein a short review.