Peri-operative adrenocortical response to low-dose (1 microg) ACTH and relation to postoperative complications in patients undergoing elective abdominal surgery

BACKGROUND: To test the hypothesis that reduced responsiveness to adrenocorticotropin (ACTH) stimulation before elective major abdominal surgery is associated with an increased incidence of postoperative complications. METHODS: A low-dose (1 microg) ACTH test was performed the day before surgery, during the operation, on the first postoperative day, and before discharge from the hospital in 77 patients undergoing major abdominal surgery (age 62 [47;69] yrs [median, quartiles]; 30 female). Thirty-one patients undergoing minor, non-abdominal surgery (mostly inguinal hernia repair) (age 57 [40;66] yrs; 14 female) served as controls with minor surgical stress. A stimulated plasma cortisol concentration >or=500 nmol/l or an increment of >or=200 nmol/l in response to 1 microg ACTH was defined as normal. Scores for surgical stress and comprehensive risk, postoperative complications, and length of hospital stay (LOS) were assessed. RESULTS: On the day before major abdominal surgery, basal and stimulated plasma cortisol were 242 (165;299) nmol/l and 497 (404;568) nmol/l, respectively. Eighteen (23%) patients had an abnormal ACTH test, and 7 of these (39%) had complications versus 25 (42%) of the 59 patients with normal ACTH tests (P = .992). Surgical stress, comprehensive risk, and intra- and postoperative basal cortisol levels were higher and the response to ACTH stimulation smaller in patients with major abdominal compared to minor surgery. The peri-operative course of ACTH responses was not associated with complications or LOS in abdominal surgery patients. CONCLUSION: In patients scheduled for abdominal surgery, pre-operatively reduced adrenal response to stimulation with 1 microg ACTH is common but not associated with postoperative complications.

Occurrence of congenital disorders in Swiss sheep.

BACKGROUND The rates of congenital disorders in Swiss sheep were determined by a questionnaire which was sent to 3,183 members of the Swiss Sheep Breeders' Association. FINDINGS A total of 993 questionnaires were returned, giving a response rate of 31.2%. Of these, 862 questionnaires originated from farms keeping one of the predominant Swiss sheep breeds: Swiss White Alpine sheep, Brown-Headed Meat sheep, Swiss Black Brown Mountain sheep and Valais Blacknose sheep. During a 10-year-period, entropion was reported in 33.6% of the farms, brachygnathia inferior in 29.5%, abdominal/umbilical hernia in 15.9%, cryptorchidism in 10.5% and torticollis in 10.5%. The most significant difference between the four breeds (P<0.001) occurred for entropion in Swiss White Alpine sheep and Brown-Headed Meat sheep, brachygnathia inferior in Swiss Black Brown Mountain sheep, and scrotal/inguinal hernia in Valais Blacknose sheep. The Swiss White Alpine breed showed a significantly higher animal prevalence of entropion (6.2% in 2011 and 5.5% in 2012) than other breeds (P<0.001). CONCLUSIONS These findings indicate a breed-specific necessity for action, particularly regarding Swiss animal welfare legislation, especially entropion in Swiss White Alpine sheep is concerned. In general, careful selection of breeding stock is to be recommended.

Congenital diaphragmatic hernia in the preterm infant.

BACKGROUND: Congenital diaphragmatic hernia (CDH) remains a significant cause of death in newborns. With advances in neonatal critical care and ventilation strategies, survival in the term infant now exceeds 80% in some centers. Although prematurity is a significant risk factor for morbidity and mortality in most neonatal diseases, its associated risk with infants with CDH has been described poorly. We sought to determine the impact of prematurity on survival using data from the Congenital Diaphragmatic Hernia Registry (CDHR). METHODS: Prospectively collected data from live-born infants with CDH were analyzed from the CDHR from January 1995 to July 2009. Preterm infants were defined as <37 weeks estimated gestational age at birth. Univariate and multivariate logistic regression analysis were>performed. RESULTS: During the study period, 5,069 infants with CDH were entered in the registry. Of the 5,022 infants with gestational age data, there were 3,895 term infants (77.6%) and 1,127 preterm infants (22.4%). Overall survival was 68.7%. A higher percentage of term infants were treated with extracorporeal membrane oxygenation (ECMO) (33% term vs 25.6% preterm). Preterm infants had a greater percentage of chromosomal abnormalities (4% term vs 8.1% preterm) and major cardiac anomalies (6.1% term vs 11.8% preterm). Also, a significantly higher percentage of term infants had repair of the hernia (86.3% term vs 69.4% preterm). Survival for infants that underwent repair was high in both groups (84.6% term vs 77.2% preterm). Survival decreased with decreasing gestational age (73.1% term vs 53.5% preterm). The odds ratio (OR) for death among preterm infants adjusted for patch repair, ECMO, chromosomal abnormalities, and major cardiac anomalies was OR 1.68 (95% confidence interval [CI], 1.34-2.11). CONCLUSION: Although outcomes for preterm infants are clearly worse than in the term infant, more than 50% of preterm infants still survived. Preterm infants with CDH remain a high-risk group. Although ECMO may be of limited value in the extremely premature infant with CDH, most preterm infants that live to undergo repair will survive. Prematurity should not be an independent factor in the treatment strategies of infants with CDH.

Treatment evolution in high-risk congenital diaphragmatic hernia: ten years' experience with diaphragmatic agenesis.

OBJECTIVE: The objective of this study was to evaluate the impact of newer therapies on the highest risk patients with congenital diaphragmatic hernia (CDH), those with agenesis of the diaphragm. SUMMARY BACKGROUND DATA: CDH remains a significant cause of neonatal mortality. Many novel therapeutic interventions have been used in these infants. Those children with large defects or agenesis of the diaphragm have the highest mortality and morbidity. METHODS: Twenty centers from 5 countries collected data prospectively on all liveborn infants with CDH over a 10-year period. The treatment and outcomes in these patients were examined. Patients were followed until death or hospital discharge. RESULTS: A total of 1,569 patients with CDH were seen between January 1995 and December 2004 in 20 centers. A total of 218 patients (14%) had diaphragmatic agenesis and underwent repair. The overall survival for all patients was 68%, while survival was 54% in patients with agenesis. When patients with diaphragmatic agenesis from the first 2 years were compared with similar patients from the last 2 years, there was significantly less use of ECMO (75% vs. 52%) and an increased use of inhaled nitric oxide (iNO) (30% vs. 80%). There was a trend toward improved survival in patients with agenesis from 47% in the first 2 years to 59% in the last 2 years. The survivors with diaphragmatic agenesis had prolonged hospital stays compared with patients without agenesis (median, 68 vs. 30 days). For the last 2 years of the study, 36% of the patients with agenesis were discharged on tube feedings and 22% on oxygen therapy. CONCLUSIONS: There has been a change in the management of infants with CDH with less frequent use of ECMO and a greater use of iNO in high-risk patients with a potential improvement in survival. However, the mortality, hospital length of stay, and morbidity in agenesis patients remain significant.

Rezidiv nach Hernienplastik: Komplikation oder natürlicher Verlauf?

Die Rezidivhäufigkeit nach Hernienplastik ist ein Qualitätsmerkmal der chirurgischen Technik. Für eine korrekte Beurteilung der Rezidivrate muss zwischen einem klinisch relevanten, klinisch irrelevanten und einem Pseudorezidiv unterschieden werden. Bei der chirurgischen Therapie von Inguinalhernien werden mit den heutigen Techniken mittels laparoskopischer oder offener Netzeinlage sehr niedrige Rezidivraten erreicht. Somit soll bei einem Rezidiv nach einer Inguinalhernienoperation von einer chirurgischen Komplikation ausgegangen werden. Im Gegensatz zur Inguinalhernie liegt die Rezidivrate bei der Operation großer Narbenhernien trotz stetiger Optimierung der Technik weiterhin über 10 %. Um das Rezidivrisiko abzuschätzen, müssen nebst der Größe und Lokalisation der Hernie technische und patientenspezifische Aspekte beurteilt werden. Je nach Risikoprofil kann das Hernienrezidiv in seltenen Fällen dem natürlichen Verlauf entsprechen. Im Allgemeinen werden Hernienrezidive als Abweichung von der Norm wahrgenommen und können von der Indikation, Wahl der Operation und der chirurgischen Technik und Taktik abhängen. Somit soll der Chirurg ein postoperatives Rezidiv in erster Linie als Komplikation und nicht als natürlichen Verlauf ansehen, mit dem Ziel die Chirurgie kontinuierlich zu verbessern.

Operation bei asymptomatischer Inguinalhernie – unnötig?

Until recently, the repair of asymptomatic groin hernia has been advocated as a prophylaxis for incarceration. However, incarcerations of inguinal hernias are rare events and can be treated adequately if the patient presents himself early after onset of symptoms. Randomized controlled trials showed, that watchful waiting is not associated with increased incarcerations and can be offered as a save alternative. However, within seven years after randomization 50 % to 70 % of the patients in the watchful waiting groups required surgery, mainly because of new onset or increasing symptoms.

Esophageal hiatal hernia in three exotic felines--Lynx lynx, Puma concolore, Panthera leo.

Hiatal hernia was diagnosed in three exotic felines-lynx (Lynx lynx), cougar (Puma concolore), and lion (Panthera leo). All cats had a history of anorexia. Thoracic and abdominal radiographs showed evidence of a soft tissue mass within the caudal mediastinum suggestive of a hiatal hernia in all animals. A barium esophagram was performed in one case. All animals underwent thoracic or abdominal surgery for hernia reduction. Surgical procedures included: intercostal thoracotomy with herniorrhaphy and esophagopexy (lynx and cougar), and incisional gastropexy (lion). Concurrent surgical procedures performed were gastrotomy for gastric foreign body removal and jejunostomy tube placement. Clinical signs related to the hiatal hernia disappeared after surgery and recurrence of signs was not reported for the time of follow-up.

Die Geschichte der Therapie der Hernia umbilicalis der Haustiere.

Lebenslauf.

Fenómeno raro de preñez, o historia de una hernia de la matriz en estado de gestacion, terminada felizmente por la operacion cesárea, con la extraccion de una niña viva ... /

Mode of access: Internet.

An inquiry into the process of nature in repairing injuries of the intestines: illustrating the treatment of penetrating wounds and strangulated hernia.

Mode of access: Internet.