Free conjunctival autologous graft for bleb repair and bleb reduction after trabeculectomy and nonpenetrating filtering surgery.

PURPOSE: To describe methods and outcomes of excisional revision of a filtering bleb (bleb revision) using free conjunctival autologous graft either for bleb repair or for bleb reduction after trabeculectomy and deep sclerectomy with an implant. METHODS: Retrospective medical records were reviewed for a consecutive non-comparative case series comprising patients who underwent excisional revision of a filtering bleb between May 1998-January 2001. Excisional revision using free conjunctival autologous graft (bleb revision) was performed either for bleb repair, to treat early and late leaks and hypotony with maculopathy, or for bleb reduction, to improve ocular pain, discomfort, burning, foreign body sensation, tearing, and fluctuations of visual acuity. The revision consisted of bleb excision and free conjunctival autologous graft. The bleb histopathology was analyzed in patients who underwent bleb repair. RESULTS: Sixteen patients were included in the study, consisting of nine patients who had a trabeculectomy and seven patients who had a deep sclerectomy with an implant. Bleb revision was necessary in 14 patients due to leaking filtering bleb (bleb repair), and in 2 patients due to bleb dysesthesia (bleb reduction). After a follow-up of 15.1 +/- 8.4 months, the mean intraocular pressure (IOP) rose from 7.8 +/- 6.3 mm Hg to 14.3 +/- 6.5 mm Hg, and the visual acuity from 0.4 +/- 0.3 to 0.7 +/- 0.3, with a P value of 0.008 and 0.03, respectively. The complete success rate at 32 months, according to the Kaplan-Meier survival curve, was 38.3%, and the qualified success rate was 83.3%. Four patients (25%) required additional suturing for persistent bleb leak. To control IOP, antiglaucoma medical therapy was needed for six patients (37.5%) and repeated glaucoma surgery was needed for one patient. CONCLUSION: Free conjunctival autologous graft is a safe and successful procedure for bleb repair and bleb reduction. However, patients should be aware of the postoperative possibility of requiring medical or surgical intervention for IOP control after revision.

Quoi de neuf en chirurgie [Novelties in surgery in 2013?].

Multidisciplinary management of colorectal liver metastases allows an increase of about 20% in the resection rate of liver metastases. It includes chemotherapy, interventional radiology and surgery. In 2013, the preliminary results of the in-situ split of the liver associated with portal vein ligation (ALLPS) are promising with unprecedented mean hypertrophy up to 70% at day 9. However, the related morbidity of this procedure is about 40% and hence should be performed in the setting of study protocol only. For pancreatic cancer, the future belongs to the use of adjuvant and neo adjuvant therapies in order to increase the resection rate. Laparoscopic and robot-assisted surgery is still in evolution with significant benefits in the reduction of cost, hospital stay, and postoperative morbidity. Finally, enhanced recovery pathways (ERAS) have been validated for colorectal surgery and are currently assessed in other fields of surgery like HPB and upper GI surgery.

Stress ulcer prophylaxis in non-critically ill patients: a prospective evaluation of current practice in a general surgery department

Objective: There is little evidence regarding the benefit of stress ulcer prophylaxis (SUP) outside critical care setting. Over-prescription of SUP is not devoid of risks. This prospective study aimed to evaluate the use of proton pump inhibitors (PPIs) for SUP in a general surgery department.Methods: Data collection was performed prospectively during an 8-week period on patients hospitalized in a general surgery department (58 beds) by pharmacists. Patients with a PPI prescription for the treatment of ulcers, gastro-oesophageal reflux disease, oesophagitis or epigastric pain were excluded. Patients admitted twice during the study period were not re-included. The American Society of Health-System Pharmacists guidelines on SUP were used to assess the appropriateness of de novo PPI prescriptions.Results: Among 255 consecutive patients in the study, 138 (54%) received a prophylaxis with PPI, of which 86 (62%) were de novo PPI prescriptions. One-hundred twenty-nine patients (94%) received esomeprazole (according to the hospital drug policy). The most frequent dosage was 40 mg/day. Use of PPI for SUP was evaluated in 67 patients. Fifty-three patients (79%) had no risk factors for SUP. Twelve and 2 patients had one or two risk factors, respectively. At discharge, PPI prophylaxis was continued in 34% of patients with a de novo PPI prescription.Conclusion: This study highlights the overuse of PPIs in non-ICU patients and the inappropriate continuation of PPI prescriptions at discharge.Treatment

Chirurgie viscérate chez le patient greffé ou en attente d'une transplantation [Visceral surgery in organ transplant recipients or in patients awaiting transplantation]

Patients receiving immunosuppression are at higher risk for gastrointestinal complications: mortality is high if they are not diagnosed and treated rapidly. Systematic screening for cholelithiasis or diverticular disease, and prophylactic surgery, are not recommended systematically anymore. Patients awaiting a transplant with abdominal symptoms should be investigated without delay and surgery, if indicated and whenever possible based on the anaesthetic evaluation, should be performed. In the transplant population, a high degree of suspicion must be raised in case of any abdominal symptom. Radiological investigations and surgery without delay are often the only ways to preserve the function of the graft and optimize the patient's survival.

Resuming motor vehicle driving following orthopaedic surgery or limb trauma.

Following elective orthopaedic surgery or the treatment of a fracture, patients are temporarily unable to drive. This loss of independence may have serious social and economic consequences for the patient. It is therefore essential to know when it is safe to permit such patients to return to driving. This article, based upon a review of the current literature, proposes recommendations of the time period after which patients may safely return to driving. Practical decisions are made based upon the type of surgical intervention or fracture. Swiss legislation is equally approached so as to better define the decision.

Ultrastructural changes of the internal limiting membrane removed during indocyanine green assisted peeling versus conventional surgery for idiopathic macular epiretinal membrane

Résumé : Introduction : L'objectif de cette étude était d'une part d'évaluer les caractéristiques histologiques des fragments cellulaires rétiniens attachés à la limitante interne après vitrectomie et pelage d'une membrane epirétinienne, et d'autre part de mettre en évidence des différences histologiques entre les cas opérés avec ou sans l'aide d'ICG dilué dans du glucose 5%. Méthodes Nous avons examiné rétrospectivement l'histologie de 88 spécimens de membranes épimaculaires contenant la limitante interne de la rétine, qui ont été enlevés chirurgicalement entre 1995 et 2003. L'analyse histologique a centré principalement l'attention sur la présence et les caractéristiques des fragments cellulaires rétiniens attachés à la limitante interne. L'analyse statistique a comparé les résultats entre le groupe I (chirurgie conventionnelle sans l'aide de l'ICG) et le groupe II (chirurgie à l'aide de l'ICG). Résultats Soixante et onze patients ont eu une vitrectomie sans l'aide de l'ICG (groupe I) et 17 avec l'aide de l'ICG (groupe II). Le nombre de débris de cellules de Müller à la surface rétinienne de la limitante interne était plus important dans le groupe I (sans ICG) que dans le groupe II (avec ICG) (40.8% versus 11.8% ; p = 0.024). Des larges fragments cellulaires rétiniens attachés à la limitante interne ont été plus fréquemment observés dans le groupe I (sans ICG) que dans le groupe II (avec ICG) (63.4% versus 23.5%; p= 0.003). Dans cinq (7%) cas du groupe I, de gros éléments cellulaires rétiniens ont été mis en évidence (des axones neuraux ou des vaisseaux sanguins). De tels éléments n'ont pas été retrouvés dans les spécimens du groupe II (avec ICG). Conclusions L'utilisation de l'ICG dilué dans du glucose 5% pour faciliter le pelage d'une membrane épimaculaire et notamment l'ablation de la limitante interne de la rétine semble diminuer de manière significative le nombre et la taille des débris des cellules de Muller adhérents à la face rétinienne de la membrane limitante interne de la rétine. Cette observation suggère que l'utilisation per-opératoire d'ICG dilué dans du glucose 5% facilite l'ablation de la limitante interne pendant la chirurgie de la membrane epirétinienne en diminuant l'adhérence de la limitante interne à la rétine.

Use of combined suspension laryngoscopy and jet ventilation for Y-shaped airway stents delivery.

Airway stenting is a common endoscopic procedure that is used to treat a variety of central airway lesions. Obstructions or fistulas involving the carina or nearby tracheobronchial structures require the use of specially designed stents, commonly referred to as Y-stents. Conventional methods of endobronchial Y-stent delivery are all characterized by a blind and apneic period during the procedure that carries the risk of stent misplacement or ventilation/oxygenation problems or both. Using combined suspension laryngoscopy, flexible bronchoscopy, and jet ventilation, we describe a technique that makes challenging bronchoscopic interventions--such as self-expandable Y-shaped airway stent delivery--easy, precise, and safe.

Systematic review o f the Perforation Risk in S tenosing Eosinophilic Esophagitis: D ilation is much s afer than initially reported

Background a nd A ims: D ilation of stenosing EosinophilicEsophagitis (EoE) is considered a high-risk procedure asperforation rates o f up to 9% of patients h ave been reported.Goal: To systematically e valuate the dilation-associatedperforation risk in stenosing EoE.Methods: A systematic review of the literature was performedusing pubmed and Embase. Keywords used were "eosinophilicesophagitis", "dilation", "perforation", and "complications".Results: F rom 2002 to 2007 7 case s eries including 85patients r eported perforations i n 5 patients ( perforation r ate6%). The highest perforation rate was reported in a series of 36patients d ocumenting 3 perforations ( 9%). In 2 010 and 2011three large studies r eporting o n a total o f 404 patientsdocumented a perforation in 3 patients (0.74%). The perforationrate reported in small case series before 2010 was significantlyhigher compared to the r ates since 2 010 ( P <0.001). Theoverall p erforation frequency is 8 /489 patients (1.6%). Amedian of 3 endoscopic sessions with dilations were performedper patient, thereby leading to a perforation rate of 0.53% perendoscopy. Follow-up information on EoE p atients w ithperforation was available in 6 s tudies, all patients c ould bemanaged conservatively, dilation-associated mortality waszero.Conclusions: D ilation of stenosing EoE h as a m uch lowerperforation risk as r eported in e arlier c ase series. Theperforation rate per endoscopy (0.53%) is much lower than theone reported for d ilation of achalasia ( 2-4%). T aking intoaccount t he latest data, dilation of stenosing EoE c an beregarded as a safe procedure.

Stricture prevention after extended circumferential endoscopic mucosal resection by injecting autologous keratinocytes in the sheep esophagus.

BACKGROUND: During the past decades, endoscopic mucosal resection (EMR) has been developed to treat early intramucosal esophageal cancers and dysplastic Barrett's esophagus. The primary drawback of this method is severe postsurgical esophageal stricture formation. The purpose of this preclinical study was to assess strategies for prevention of this major complication by injecting autologous keratinocytes in the EMR mucosal defect in the sheep model. METHODS: Circumferential, 6-cm-long EMRs were performed in the esophagus of nine sheep. Autologous keratinocytes were harvested 2 weeks before EMR and cultured. Circumferential resection consisted of two opposite hemicircumferential mucosectomies allowing a widespread resection of 24 cm(2). Immediately after EMR, autologous keratinocytes were endoscopically injected in the mucosal defect. Animals were sacrificed after 6 months. RESULTS: Circumferential EMRs were successfully performed in all animals. There were no intra- or postoperative complications. None of the animals developed strictures. All animals were sacrificed at 6 months as planned. Histological examinations showed fibrotic changes in 10 % (range 0-25 %) of the circumferential muscularis propria interna layer and 7.2 % (range 0-25 %) in the muscularis propria externa layer at the midportion of the EMR. No circumferential transmural fibrosis was identified. CONCLUSIONS: Prevention of stricture formation after extensive (6-cm long) circumferential EMR of the sheep esophagus can be achieved by injecting autologous keratinocytes into the wound of the resected mucosal segment.

Diffuse nesidioblastosis with hypoglycemia mimicking an insulinoma: a case report.

INTRODUCTION: We describe a case of diffuse nesidioblastosis in an adult patient who presented with exclusively fasting symptoms and a focal pancreatic 111In-pentetreotide uptake mimicking an insulinoma. CASE PRESENTATION: A 23-year-old Caucasian man had severe daily fasting hypoglycemia with glucose levels below 2mmol/L. Besides rare neuroglycopenic symptoms (confusion, sleepiness), he was largely asymptomatic. His investigations revealed low venous plasma glucose levels, high insulin and C-peptide levels and a 72-hour fast test that were all highly suggestive for an insulinoma. Abdominal computed tomography and magnetic resonance imaging did not reveal any lesions. The sole imagery that was compatible with an insulinoma was a 111In-somatostatin receptor scintigraphy that showed a faint but definite focal tracer between the head and the body of the pancreas. However, this lesion could not be confirmed by endoscopic ultrasonography of the pancreas. Following duodenopancreatectomy, the histological findings were consistent with diffuse nesidioblastosis. Postoperatively, the patient continued to present with fasting hypoglycemia and was successfully treated with diazoxide. CONCLUSION: In the absence of gastrointestinal surgery, nesidioblastosis is very rare in adults. In addition, nesidioblastosis is usually characterized by post-prandial hypoglycemia, whereas this patient presented with fasting hypoglycemia. This case also illustrates the risk for a false positive result of 111In-pentetreotide scintigraphy in the case of nesidioblastosis. Selective arterial calcium stimulation and venous sampling is the most reliable procedure for the positive diagnosis of insulinoma or nesidioblastosis and should be used to confirm any suspicion based on imaging modalities.

Pulse pressure variation-guided fluid therapy after cardiac surgery: A pilot before-and-after trial.

PURPOSE: The aim of this study is to study the feasibility, safety, and physiological effects of pulse pressure variation (PPV)-guided fluid therapy in patients after cardiac surgery. MATERIALS AND METHODS: We conducted a pilot prospective before-and-after study during mandatory ventilation after cardiac surgery in a tertiary intensive care unit. We introduced a protocol to deliver a fluid bolus for a PPV ≥13% for at least >10 minutes during the intervention period. RESULTS: We studied 45 control patients and 53 intervention patients. During the intervention period, clinicians administered a fluid bolus on 79% of the defined PPV trigger episodes. Median total fluid intake was similar between 2 groups during mandatory ventilation (1297 mL [interquartile range 549-1968] vs 1481 mL [807-2563]; P = .17) and the first 24 hours (3046 mL [interquartile range 2317-3982] vs 3017 mL [2192-4028]; P = .73). After adjusting for several baseline factors, PPV-guided fluid management significantly increased fluid intake during mandatory ventilation (P = .004) but not during the first 24 hours (P = .47). Pulse pressure variation-guided fluid therapy, however, did not significantly affect hemodynamic, renal, and metabolic variables. No serious adverse events were noted. CONCLUSIONS: Pulse pressure variation-guided fluid management was feasible and safe during mandatory ventilation after cardiac surgery. However, its advantages may be clinically small.

Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations.

BACKGROUND & AIMS: Protocols for enhanced recovery provide comprehensive and evidence-based guidelines for best perioperative care. Protocol implementation may reduce complication rates and enhance functional recovery and, as a result of this, also reduce length-of-stay in hospital. There is no comprehensive framework available for pancreaticoduodenectomy. METHODS: An international working group constructed within the Enhanced Recovery After Surgery (ERAS®) Society constructed a comprehensive and evidence-based framework for best perioperative care for pancreaticoduodenectomy patients. Data were retrieved from standard databases and personal archives. Evidence and recommendations were classified according to the GRADE system and reached through consensus in the group. The quality of evidence was rated "high", "moderate", "low" or "very low". Recommendations were graded as "strong" or "weak". RESULTS: Comprehensive guidelines are presented. Available evidence is summarised and recommendations given for 27 care items. The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations. CONCLUSIONS: The present evidence-based guidelines provide the necessary platform upon which to base a unified protocol for perioperative care for pancreaticoduodenectomy. A unified protocol allows for comparison between centres and across national borders. It facilitates multi-institutional prospective cohort registries and adequately powered randomised trials.