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.

Les vertébroplasties: point de vue du rhumatologue [Vertebro-plasty: a rheumatologist's point of view]

Percutaneous vertebro-plasty is an efficient treatment of the symptomatic vertebral compression fracture refractory to optimal medical therapy. The procedure is used for neoplastic lesions, aggressive angioma, but also osteoporotic compression fractures. In order to adequately advice our patients, it is essential to know its indications and possible complications. However, to practice a vertebro-plasty for an osteoporotic compression fracture without any long term management of the osteoporotic disease is useless. Unfortunately, it still happens too often and it is essential that orthopedic surgeons, general practitioner, radiologist, rheumatologist, and any practitioners work together to guarantee the optimal management of our patients.

Gestion des hypoglycémies après le bypass gastrique [Management of hyperinsulinemic hypoglycemia post-gastric bypass surgery].

Gastric bypass surgery is an effective treatment for morbid obesity, allowing a substantial weight loss together with an improvement of the cardiovascular and metabolic comorbidities, particularly the glucose control. However, after gastric bypassing, an imbalance between sensitivity and insulin secretion may be observed. This disorder gives rise to hyperinsulinemic hypoglycemia (late dumping syndrome) and is characterized by a dizziness that can be disabling. This problem must be distinguished from conditions provoking similar symptoms, as for instance the early dumping syndrome and the food restriction-related hypoglycemia. Since all these conditions need a particular management, their distinction is essential.

Blood glucose level on postoperative day 1 is predictive of adverse outcomes after cardiovascular surgery.

AIM: Hyperglycaemia is now a recognized predictive factor of morbidity and mortality after coronary artery bypass grafting (CABG). For this reason, we aimed to evaluate the postoperative management of glucose control in patients undergoing cardiovascular surgery, and to assess the impact of glucose levels on in-hospital mortality and morbidity. METHODS: This was a retrospective study investigating the association between postoperative blood glucose and outcomes, including death, post-surgical complications, and length of stay in the intensive care unit (ICU) and in hospital. RESULTS: A total of 642 consecutive patients were enrolled into the study after cardiovascular surgery (CABG, carotid endarterectomy and bypass in the lower limbs). Patients' mean age was 68+/-10 years, and 74% were male. In-hospital mortality was 5% in diabetic patients vs 2% in non-diabetic patients (OR: 1.66, P=0.076). Having blood glucose levels in the upper quartile range (> or =8.8 mmol/L) on postoperative day 1 was independently associated with death (OR: 10.16, P=0.0002), infectious complications (OR: 1.76, P=0.04) and prolonged ICU stay (OR: 3.10, P<0.0001). Patients presenting with three or more hypoglycaemic episodes (<4.1 mmol/L) had increased rates of mortality (OR: 9.08, P<0.0001) and complications (OR: 8.57, P<0.0001). CONCLUSION: Glucose levels greater than 8.8 mmol/L on postoperative day 1 and having three or more hypoglycaemic episodes in the postoperative period were predictive of mortality and morbidity among patients undergoing cardiovascular surgery. This suggests that a multidisciplinary approach may be able to achieve better postoperative blood glucose control.

Surgical outcomes following repeat non-penetrating glaucoma filtration surgery at a tertiary referral centre

Purpose:To determine the surgical outcomes of patients undergoing repeat deep sclerectomies with collagen implant (DSCI) at a tertiary referral centre. Methods:The medical notes of 208 patients undergoing multiple DSCI were reviewed. Those undergoing repeat DSCI were identified and post operative data for each DSCI were analysed. Group A: the first DSCI; group B: second DSCI; group C: third DSCI. Results:Mean age was 66.8 ±13.0 years. At 12 months, percentage of mean IOP reduction in groups were 18%, 24% and 17% respectively. Mean interval to starting glaucoma medications, re-operation, mitomycin injection and goniopuncture all decreased as the number of operations increased. There was a significant reduction in complete success rates between groups A and B and groups B and C. Few minor complications were observed in all 3 groups. Conclusions:Despite the possibility of bleb independent outflow pathways in patients undergoing non-penetrating surgery, there are significantly reduced success rates in eyes undergoing repeat DSCI. This has important implications for the choice of subsequent operations in patients who have failed non-penetrating filtration surgery.

Evaluation des modifications anatomiques et fonctionnelles de la macula après chirurgie des membranes néovasculaires rétrofovéolaires dans la dégénérescence maculaire liée à l'âge [Evaluation of functional and anatomical changes in the macula after surgery for retro-foveal neovascularization of membranes in age-related macular degeneration].

PURPOSE: The aim of this study was to evaluate the direct effect of surgical treatment of subfoveolar neovascular membranes in age related macular degeneration to macular functions. PATIENTS AND METHODS: Thirteen eyes of 13 patients were included in this study. Macular function was assayed by visual acuity and central visual field using the Octopus perimeter before surgery and in the first three post operative months. Pre and post operative fluorescein angiography frames were digitalized and the size of each lesions were compared. RESULTS: After a 3 months follow up, visual acuity remained stable or improved in 66% of the patients. However, visual acuity was better than 0.1 in 15% of the patients. Central visual field comparison disclosed a significant worsening of the retinal sensitivity in the 3 degree field surrounding the central point. On fluorescein frames, submacular scar was 141% of the size of the neovascular membrane. After a mean follow up of 6.9 months (range 3-14), one case of recurrence occurred. A cataract was observed in 85% of the phakic patients followed for more than six months. CONCLUSION: After a short term follow up, surgery can stabilise visual acuity, even though it remains poor. A worsening of the scotoma in the 3 degrees surrounding the central point is observed. However, patients noticed a subjective visual improvement in 62% of the case.

Cell Therapy Assistance in Reconstructive Surgery for Musculoskeletal Tissues Following Burn and Trauma: Swiss Cellular Transplantation Platform

The sterol compositions of three oceanic jellyfish have been determined using gas chromatographic mass spectrometric techniques involving the use of two separate gas chromatographic column systems. The components in overlapping peaks have been identified by comparison of the mass spectra of peaks in the two column systems using subtractive techniques. A mid-water animal, Periphylla periphylla, was found to contain a very complex and unusual sterol profile including rare 5alpha-stanols, whereas two other oceanic jellyfish Pelagia noctiluca and Atolla wyvillei contained similar mixtures of delta5 sterols to those previously isolated from coastal species.

Spinal modulations accompany peripheral fatigue during prolonged tennis playing.

To examine the time course of alteration in neural process (spinal loop properties) during prolonged tennis playing, 12 competitive players performed a series of neuromuscular tests every 30 min during a 3-h match protocol. Muscle activation (twitch interpolation) and normalized EMG activity were assessed during maximal voluntary contraction (MVC) of plantar flexors. Spinal reflexes and M-waves were evoked at rest (i.e., H(max) and M(max) , respectively) and during MVC (i.e., H(sup) , V-wave, M(sup) , respectively). MVC torque declined significantly (P<0.001) across the match protocol, due to decrease (P<0.001) in muscle activation and in normalized EMG activity. The impairment in MVC was significantly correlated (r=0.77; P<0.05) with the decline in muscle activation. H(max) /M(max) (P<0.001), H(sup) /M(sup) (P<0.01) and V/M(sup) (P<0.05) ratios were depressed with fatigue and decreased by ∼80%, 46% and 61% at the end of exercise, respectively. Simultaneously, peak twitch torque and M-wave amplitude were significantly (P<0.01) altered with exercise, suggesting peripheral alterations. During prolonged tennis playing, the compromised voluntary strength capacity is linked to a reduced neural input to the working muscles. This central activation deficit partly results from a modulation in spinal loop properties.

Spinal cord ischemia : clinical and imaging patterns, pathogenesis, and outcomes in 27 patients

RÉSUMÉ Introduction: l'histoire naturelle et la physiopathologie des infarctus de la moelle épinière restent largement inconnues. En effet, la plupart des études cliniques portent sur des patients qui ont souffert d'infarctus médullaire secondaire à des chirurgies aortiques ou des hypotensions prolongées. Méthode: ce travail analyse les données cliniques, le laboratoire, l'imagerie (IRM) et l'évolution de 27 patients souffrant d'infarctus de la moelle épinière admis dans le service de Neurologie du CHUV. Parmi ces patients, il y avait 11 hommes et 16 femmes (âge moyen de 56 ans, tranche d'âge de 19 à 80 ans). Résultats: dix patients (37%) souffraient d'infarctus de l'artère spinale antérieure, 4 (15%) d'infarctus unilatéraux antérieurs, 4 (15%) unilatéraux postérieurs, 3 (11%) d'infarctus centraux, 2 (7%) d'infarctus des artères spinales postérieures, 2 (7%) d'infarctus transverse tandis que 2 patients présentaient des tableaux cliniques inclassables. Vingt patients (74%) n'avaient pas d'étiologie identifiable. Les patients avec infarctus centraux ou transverses présentaient fréquemment (40%) des artériopathies périphériques et tous les infarctus transverses survenaient à la suite d'hypotensions artérielles prolongées. Le début de tous les autres types d'infarctus était associé à des facteurs mécaniques (p=0.02} et ces patients avaient fréquemment des pathologies du rachis (p=0.003) au niveau de la lésion médullaire. Dans ces cas, les données cliniques suggèrent une lésion d'une racine nerveuse au niveau de l'infarctus médullaire compromettant mécaniquement le flux de son artère radiculaire. L'évolution clinique était généralement favorable, seuls 13 patients (48%) présentaient une atteinte significative de la marche à la sortie de l'hôpital. Conclusion: ce travail montre qu'il existe 2 types principaux d'infarctus de la moelle épinière : d'une part les infarctus dans le territoire d'une artère radiculaire (infarctus de l'artère spinale antérieure, des artères spinales postérieures et infarctus unilatéraux) et d'autre part les hypoperfusions régionales globales de la moelle épinière (infarctus centraux et transverses). Chacune de ces 2 catégories d'infarctus ont des caractéristiques cliniques, radiologiques, physiopathologiques et pronostiques distinctes.

Management of a post-operative multi-resistant infectious spondylitis associated with a kyphotic deformity.

Anterior spinal infection (prevertebral abscess and/or discitis) after posterior instrumentation for vertebral fractures is a challenging complication, since a new implant may become necessary anteriorly, in a septic environment. Generally accepted management guidelines are yet to be established. The authors present a case of posterior instrumentation for fractures of T12 and L1, complicated after 9 months with an anterior infection (prevertebral abscess and discitis) with extended-spectrum beta-lactamase (ESBL) producing Escherichia coli (E. coli). This case is unique in that the multi-resistant organism was isolated only after the second stage of infection treatment, which consisted of anterior débridement and anterior implantation of titanium cages and rods. In this particular case, infection was controlled despite implantation of multiple cages, screws and rods, and fusion was achieved, by means of intravenous antibiotic treatment for 12 months. At the latest follow-up, 24 months post surgery, there was no evidence of infection. This problem case may be helpful for surgeons confronted with spinal deformities secondary to infections with multi-resistant organisms.

Oral mucosal melanoma: conservative treatment including laser surgery.

Objective: To discuss the convenience of laser surgery as optimal treatment for melanoma of the oral mucosa.Patients and methods: A retrospective evaluation of four patients with primary oral melanomas treated at a single Cancer Institution in Mexico City.Results: Two patients were treated with resection of the melanoma with CO2 laser together with extraction of the involved dental organs and curettage of the alveolar walls. These two cases had melanoma in situ with multiple isolated foci. The third patient had a lesion with vertical growth, who was submitted to partial maxillectomy along with selective dissection of bilateral neck levels I-V with a negative report and the fourth patient had a history of oral nodular melanoma and presented with lymph node metastasis. According to follow-up status, there was no distant metastasis in any of the patients reported here.Conclusion: In our experience, conservative management with CO2 laser is adequate for melanomas of the oral mucosa with extraction of the dental organs and curettage of the alveoli to achieve complete surgical resection microscopically without sacrifice of the quality of life. Management of the neck is controversial. We recommend selective therapeutic resection of the neck only if it is found to be clinically positive. Elective dissection has not shown to have an impact in overall survival.

Perioperative nutrition in abdominal surgery: recommendations and reality.

Introduction. Preoperative malnutrition is a major risk factor for increased postoperative morbidity and mortality. Definition and diagnosis of malnutrition and its treatment is still subject for controversy. Furthermore, practical implementation of nutrition-related guidelines is unknown. Methods. A review of the available literature and of current guidelines on perioperative nutrition was conducted. We focused on nutritional screening and perioperative nutrition in patients undergoing digestive surgery, and we assessed translation of recent guidelines in clinical practice. Results and Conclusions. Malnutrition is a well-recognized risk factor for poor postoperative outcome. The prevalence of malnutrition depends largely on its definition; about 40% of patients undergoing major surgery fulfil current diagnostic criteria of being at nutritional risk. The Nutritional Risk Score is a pragmatic and validated tool to identify patients who should benefit from nutritional support. Adequate nutritional intervention entails reduced (infectious) complications, hospital stay, and costs. Preoperative oral supplementation of a minimum of five days is preferable; depending on the patient and the type of surgery, immune-enhancing formulas are recommended. However, surgeons' compliance with evidence-based guidelines remains poor and efforts are necessary to implement routine nutritional screening and nutritional support.