Robotic cholecystectomy for acute cholecystitis: Three case reports.

INTRODUCTION: Nowadays laparoscopic cholecystectomy is considered as criterion standard for surgical treatment of acute calculous cholecystitis. During the last few years, there has been growing interest about the robotic approach. Several authors have reported the superiority of robotic cholecystectomy, associated with a lower percentage of conversion especially in patients with intraoperative diagnosis of acute or gangrenous cholecystitis. We report 3 case reports of moderate acute cholecystitis successfully treated by robotic cholecystectomy. PATIENT CONCERNS: Three patients presented moderate acute calculous cholecystitis with leukocytosis, fever, nausea, vomiting, and pain. DIAGNOSIS: Three patients of our study population had clinical and laboratory suspicion of moderate acute calculous cholecystitis verified by abdominal ultrasound examination, which found out cholelitiasis in all 3 cases. Final diagnosis was confirmed by intraoperative findings and histopathological examination, with two empyematous cholecystitis and one perforated cholecystitis. INTERVENTIONS: All patients underwent robotic cholecystectomy with the da Vinci Robotic Surgical System. The entire procedure required a mean operation time of 128 minutes and the average blood loss was 60 mL, without any intraoperative complications. OUTCOMES: In all 3 cases postoperative period was uneventfull. All the patients were discharged within 24 hours and no readmissions were reported during a 30 days' follow-up. CONCLUSIONS: Robotic cholecystectomy for ACC is feasible and safe. Several studies have demonstrated that robotic approach reduces the risk of conversion to open surgery in case of acute or gangrenous cholecystitis. Our results are in line with current literature. In fact, we have successfully treated 2 patients with empyematous acute cholecystitis and 1 with gangrenous cholecystitis with a totally robotic approach, without any complications or need of conversion to open surgery. In conclusion, our results confirm that it is the time to include robotic surgery in the emergency setting.

Serum biomarkers for sepsis in children with febrile neutropenia and cancer.

The National Institute for Health and Care Excellence (NICE) defines febrile neutropenia or "neutropenic sepsis" as a patient with an absolute neutrophil count (ANC) less than 0.5 x 109/L and temperature >38°C or signs and symptoms of sepsis.

Multimedia article. Laparoscopic treatment of chronic sigmoid volvulus in a young adult.

INTRODUCTION: Sigmoid volvulus is responsible for 8% of all intestinal obstructions. The most frequent presentation is in the elderly, with it occurring exceptionally in young people. Surgical resection is mandatory to prevent recurrence. Laparoscopic maneuvers in the long and distended bowel are difficult, and not much experience with these procedures has been reported. MATERIALS AND METHODS, AND RESULTS: A 21-year-old man with antecedents of constipation had two episodes of rectal prolapse, and one episode of acute volvulation treated with decompressive endoscopy. A laparoscopic exploration was performed for definitive treatment. Transanal intubation with a large-bore tube permitted deflation of the bowel. A deep Douglas's pouch was observed with a mobile sigmoid loop that intussuscepted the rectum. A proctosigmoidectomy including the 5 cm of the upper rectum was performed without incident. CONCLUSION: Laparoscopic management of suboclusive colonic volvulus is feasible. Intraopertive transanal intubation permits deflation the loop and facilitates manipulation.

Oesophageal achalasia in elderly people: results of the laparoscopic Heller-Dor myotomy.

AIMS: To assess the outcome of laparoscopic Heller-Dor myotomy for oesophageal achalasia in two groups of patients identified by age (under and over 70 years) using functional and clinical instruments. BACKGROUND: Current therapies for achalasia can't restore normal motility but can palliate dysphagia. Many other symptoms may persist difficult to quantify and to compare. In order to understand if age is a factor that influences the therapeutic outcome we tested the reliability of a specific QoL instrument for comparing outcomes of surgery for achalasia. METHODS: Functional examinations and the Gastrointestinal Quality of Life Index (GIQLI) were used before and after laparoscopic Heller-Dor myotomy. RESULTS: Starting in January 1996, 28 consecutive patients of 32 diagnosed (instrumental evidences) achalasia were operated on laparoscopically for various clinical stages of achalasia. In 78% of patients dysphagia disappeared, the incidence of gastro-oesophageal reflux was of 11%. The patients completed a GIQLI questionnaire preoperatively and after a minimum postoperative follow-up of 1 year. Median preoperative GIQLI score was 78(range 38-109) out of a theoretical maximum score of 144. At a median follow-up of 35 months (range 18-72), the score had significantly improved to 115 (range 71-140). All the items assessing gastrointestinal symptoms and physical, social, and emotional function were significantly improved. There is no difference between the two groups identified. CONCLUSIONS: The laparoscopic Heller-Dor myotomy is an effective palliation for acalasia, the medium-term outcome is not affected by the age of the patients. The GIQLI is a reliable instrument to compare the impact of achalasia symptoms on health-related QoL.

Ultrarapid opioid detoxification: effects on cardiopulmonary physiology, stress hormones and clinical outcomes.

This study explored the acute and long-term consequences of ultrarapid opioid detoxification (URD) in individuals with opioid dependence. In an open case series, seven patients underwent URD and subsequent treatment with daily naltrexone. Structured interviews, integrated rehabilitation and hair sampling were employed in the 12-week course of longitudinal follow-up. Cardiac and pulmonary physiology did not change significantly during the anesthesia phase of URD, but plasma ACTH and cortisol levels increased 15- and 13-fold, respectively. Marked withdrawal and tachypnea in all patients and respiratory distress in one patient occurred during the acute post-anesthesia phase. Withdrawal scores were significantly elevated for 3 weeks compared with baseline in the face of minimal self-reported craving for opioids. Anxiety, depression and vegetative symptoms improved gradually. Four patients remained abstinent of opioid use, two reported a brief period of opioid intake and one relapsed into daily opioid consumption. Given its effect on breathing and stress hormones, this procedure should be conducted by experienced anesthesiologists. The fact that URD and subsequent naltrexone treatment appears to cause a dissociation effect in the usual relationship between withdrawal and craving has implications for behavioral pharmacology. Further research is needed on the efficacy, safety, mechanisms and neurobiological sequelae of the procedure.

Institutional variability in red blood cell conservation practices for coronary artery bypass graft surgery. Institutions of the MultiCenter Study of Perioperative Ischemia Research Group.

OBJECTIVE: To assess whether substantial institutional variability exists in red blood cell conservation practices associated with coronary artery bypass graft (CABG) surgery. DESIGN: Prospective, randomized patient enrollment and data collection. SETTING: Twenty-four U.S. academic institutions participating in the Multicenter Study of Perioperative Ischemia. PARTICIPANTS: A well-defined subset of primary CABG surgery patients (n = 713) expected to be at low risk for bleeding and exposure to allogeneic transfusion. INTERVENTIONS: None (observational study). MEASUREMENTS AND MAIN RESULTS: Frequency of use of red blood cell conservation techniques was determined among institutions. Correlation was determined between use of each technique and transfusion of allogeneic red blood cells and between use of each technique and median institutional blood loss. Significant variability (p < 0.01) was detected in institutional transfusion practice with respect to the use of predonated autologous whole blood, normovolemic hemodilution, red cell salvage, and reinfusion of shed mediastinal blood. The frequency of institutional use of these techniques was not associated with allogeneic transfusion (r2 < 0.15) or blood loss (r2 < 0.10) in the low-risk population of patients examined. CONCLUSIONS: Institutions vary significantly in perioperative blood conservation practices for CABG surgery. Further study to determine the appropriate use of these techniques is warranted.

Safety and efficacy of shed mediastinal blood transfusion after cardiac surgery: a multicenter observational study. Multicenter Study of Perioperative Ischemia Research Group.

OBJECTIVE: To examine the efficacy and safety of shed mediastinal blood (SMB) transfusion in preventing allogenic red blood cell (RBC) transfusion. DESIGN: An observational clinical study. SETTING: Twelve US academic medical centers. PARTICIPANTS: Six hundred seventeen patients undergoing elective primary coronary artery bypass grafting. INTERVENTIONS: Patients were administered SMB transfusion or not, according to institutional and individual practice, without random assignment. MEASUREMENTS AND RESULTS: The independent effect of SMB transfusion on postoperative RBC transfusion was examined by multivariable modeling. Potential complications of SMB transfusion, such as bleeding and infection, were examined. Three hundred twelve of the study patients (51%) received postoperative SMB transfusion (mean volume, 554 +/- 359 mL). Patients transfused with SMB had significantly lower volumes of RBC transfusion than those not receiving SMB (0.86 +/- 1.50 v 1.08 +/- 1.65 units; p < 0.05). However, multivariable analysis showed that SMB transfusion was not predictive of postoperative RBC transfusion. Demographic factors (older age, female sex), institution, and postoperative events (greater chest tube drainage, lower hemoglobin level on arrival to the intensive care unit, and use of inotropes) were significant predictors of RBC transfusion. The volume of chest tube drainage on the operative day (707 +/- 392 v 673 +/- 460 mL; p = 0.30), reoperation for hemorrhage (3.1% v2.5%; p = 0.68), and overall frequency of infection (5.8% v 6.6%; p = 0.81) were similar between patients receiving and not receiving SMB, respectively. However, in patients who did not receive allogenic RBC transfusion, there was a significantly greater frequency of wound infection in the SMB group (3.6% v0%; p = 0.02). CONCLUSION: These data suggest that SMB is ineffective as a blood conservation method and may be associated with a greater frequency of wound infection.

Hematocrit value on intensive care unit entry influences the frequency of Q-wave myocardial infarction after coronary artery bypass grafting. The Institutions of the Multicenter Study of Perioperative Ischemia (McSPI) Research Group.

OBJECTIVES: No data exist regarding "the best" hematocrit value after coronary artery bypass graft surgery. Transfusion practice varies, because neither an optimal hematocrit value nor a uniform transfusion trigger criterion has been determined. METHODS: To investigate the optimal hematocrit value, we studied 2202 patients undergoing coronary bypass. The hematocrit value on entry into the intensive care unit (IHCT) was categorized into three groups: high (> or = 34%), medium (25% to 33%), and low (< or = 24%). Characteristics and adverse events (outcomes) were compared, and the effect of IHCT on the risk of myocardial infarction was determined by logistic regression. RESULTS: High IHCT (> or = 34%) was associated with an increased rate of myocardial infarction (8.3% vs 5.5% vs 3.6%; p < or = 0.03, high, medium vs low) and with more severe left ventricular dysfunction (11.7% vs 7.4% and 5.7%; p=0.006, high, medium vs low). Mortality rate increased with higher IHCT when all the high-risk subgroups were combined (8.6% vs 4.5% vs 3.2%; p < 0.001, high, medium vs low). By multivariate analysis, IHCT remained the most significant predictor of adverse outcomes (relative risk high vs low 2.22, 95% confidence interval: 1.04 to 4.76). No characteristic, event, medication, or transfusion therapy confounded the relationship between IHCT and outcome. CONCLUSION: High IHCT is associated with a higher rate of myocardial infarction and is an independent predictor of infarction. On the basis of the risk of myocardial infarction, there is no rationale for transfusion to an arbitrary level after coronary artery bypass grafting.

Variability in transfusion practice for coronary artery bypass surgery persists despite national consensus guidelines: a 24-institution study. Institutions of the Multicenter Study of Perioperative Ischemia Research Group.

BACKGROUND: An estimated 20% of allogeneic blood transfusions in the United States are associated with cardiac surgery. National consensus guidelines for allogeneic transfusion associated with coronary artery bypass graft (CABG) surgery have existed since the mid- to late 1980s. The appropriateness and uniformity of institutional transfusion practice was questioned in 1991. An assessment of current transfusion practice patterns was warranted. METHODS: The Multicenter Study of Perioperative Ischemia database consists of comprehensive information on the course of surgery in 2,417 randomly selected patients undergoing CABG surgery at 24 institutions. A subset of 713 patients expected to be at low risk for transfusion was examined. Allogeneic transfusion was evaluated across institutions. Institution as an independent risk factor for allogeneic transfusion was determined in a multivariable model. RESULTS: Significant variability in institutional transfusion practice was observed for allogeneic packed red blood cells (PRBCs) (27-92% of patients transfused) and hemostatic blood components (platelets, 0-36%; fresh frozen plasma, 0-36%; cryoprecipitate, 0-17% of patients transfused). For patients at institutions with liberal rather than conservative transfusion practice, the odds ratio for transfusion of PRBCs was 6.5 (95% confidence interval [CI], 3.8-10.8) and for hemostatic blood components it was 2 (95% CI, 1.2-3.4). Institution was an independent determinant of transfusion risk associated with CABG surgery. CONCLUSIONS: Institutions continue to vary significantly in their transfusion practices for CABG surgery. A more rational and conservative approach to transfusion practice at the institutional level is warranted.

Effect of recombinant human erythropoietin on transfusion risk in coronary bypass patients.

BACKGROUND: Patients having a cardiac operation frequently require allogeneic blood transfusions despite surgical blood-conservation techniques. Recombinant human erythropoietin (Epoetin alfa) may augment this conservation by stimulating erythropoiesis. The safety and efficacy of perioperative use of Epoetin alfa to reduce the need of allogeneic transfusion was studied. METHODS: A multicenter double-blind, placebo-controlled, parallel-group study involved 182 patients having coronary artery bypass grafting and randomized to receive Epoetin alfa (300 or 150 IU/kg) or placebo subcutaneously for 5 days before, on the day of, and for 2 days after operation. RESULTS: Perioperative Epoetin alfa resulted in greater increases in baseline to preoperative hemoglobin levels and hematocrit (300 IU/kg) and in presurgery to postsurgical day 1 reticulocyte counts versus placebo (p < or = 0.05). However, there was no significant difference in transfusion requirements. Incidences of adverse events were similar in all study groups. CONCLUSIONS: Lower incidences of allogeneic blood exposure were observed in both Epoetin alfa-treated groups; however, the differences between all treatment groups were not significant. This was probably due to the relatively short 5-day preoperative course of Epoetin alfa therapy. There were no significant differences between the three groups relative to safety. Epoetin alfa was well tolerated in this population.

Aprotinin in primary valve replacement and reconstruction: a multicenter, double-blind, placebo-controlled trial.

BACKGROUND: Patients having cardiac operations often require blood transfusions. Aprotinin reduces the need for blood transfusions during coronary artery bypass graft operations. To determine the safety and effectiveness of aprotinin in reducing the use of allogeneic blood and postoperative mediastinal chest tube drainage, we studied 212 patients undergoing primary sternotomy for valve replacement or repair. METHODS: This study was multicenter, randomized, prospective, double-blind, and placebo-controlled. Patients received high-dose aprotinin (n = 71), low-dose aprotinin (n = 70), or placebo (n = 71). The study medication was given as a loading dose followed by a continuous infusion and pump prime dose. Heparin administration was standardized. Transfusions, postoperative mediastinal shed blood, and adverse events were tracked. RESULTS: Demographic profiles were similar among the treatment groups. Aprotinin did not decrease the percentage of patients receiving transfusions when compared with placebo (high-dose aprotinin, 63%, p = 0.092; low-dose aprotinin, 52%, p = 0.592; placebo, 48%). Aprotinin was associated with a reduction in the volume of mediastinal shed blood (high-dose aprotinin vs placebo, p = 0.002; low-dose aprotinin vs placebo, p = 0.017). Adverse events were equally distributed among the treatment groups except for postoperative renal dysfunction (high-dose aprotinin, 11%; low-dose aprotinin, 7%; placebo, 0%; p = 0.01). A disproportionate number of patients in the high-dose aprotinin group with postoperative renal dysfunction also had diabetes mellitus. CONCLUSIONS: Aprotinin treatment in this population did not reduce allogeneic blood use, although there were significant reductions in the volume of mediastinal shed blood.

Restoration of the normal coagulation process: advances in therapies to antagonize heparin.

A number of naturally occurring anticoagulants exist that preserve normal blood fluidity and limit blood clot formation to vascular injury sites, thus acting as regulators of hemostasis. The protein C/protein S pathway is one system that acts to modulate thrombin formation. The activation of protein C by thrombin is accelerated more than 1,000-fold at the endothelial surface by thrombomodulin localized on the endothelial cell. Activated protein C then binds to its co-factor, protein S, and the protein C/protein S complex exerts its antithrombotic function by inactivating the coagulation factors Va and VIIIa. Patients deficient in protein C and protein S may be particularly vulnerable to thrombotic events after cardiac surgery. In addition, several studies suggest that reductions in protein C and protein S concentrations, as well as thrombomodulin, occur during cardiopulmonary bypass (CPB). The possibility of a low anticoagulant potential when heparinization is reversed may be an important factor in the subsequent morbidity associated with thrombotic complications. Aprotinin is a serine protease inhibitor that in vitro binds competitively with the serine protease-activated protein C. However, aprotinin in the clinical setting has not been reported to alter levels of protein C in patients undergoing CPB. Reversal of the heparinization needed for CPB is almost universally performed with protamine. However, protamine has many deleterious effects. Recombinant platelet factor 4 (rPF4) has been proposed as an alternative to protamine. We investigated the effective heparin neutralization dose of rPF4 vs. the standard agent protamine in human blood activated through exposure to the CPB circuit. Activated clotting time (ACT) measurements suggested a 2:1 (w/w) reversal ratio for rPF4 and protamine. The first human open-label phase 1 trial of rPF4 reported no serious side effects and no important hemodynamic effects. Doses of 2.5 and 5.0 mg/kg were uniformly effective in reversing the anticoagulant effect of heparin and reducing the ACT to <200 s by 5 min after administration. Repeated monitoring of the ACT did not detect a rebound effect of heparin.

Alternatives to allogeneic blood use in surgery: acute normovolemic hemodilution and preoperative autologous donation.

Acute normovolemic hemodilution (ANH) is a common blood conservation strategy in elective surgical procedures. Moderate ANH is safe in patients > 60 years of age; ANH is not recommended for patients who have coronary artery disease, significant anemia, renal disease, severe hepatic disease, pulmonary emphysema, or obstructive lung disease. Preservation of oxygen delivery during ANH depends on the maintenance of normovolemia to avoid decompensation and falling cardiac output. Preoperative autologous donation (PAD) as a blood conservation strategy has the advantage of protecting the patient from risks associated with allogenic transfusion, but it is expensive and time consuming. No protocols have established a preference for either ANH or PAD; an early study suggested that ANH is less expensive and more effectively preserves blood components, but other researchers warn that the methodology for ANH remains unresolved.

Distal circulatory support for thoracic aortic operations: effects on intracranial pressure.

Spinal cord ischemia can result from aortic clamping during thoracic aortic operations. The perfusion gradient for spinal cord perfusion is positively influenced by distal aortic pressure and negatively influenced by intracranial pressure (ICP). Hemodynamic and ICP changes were examined in a swine model of descending thoracic aortic surgery where distal aortic perfusion was achieved under one of three conditions: (1) clamping without support, (2) a passive aortofemoral shunt, or (3) a left atrium-femoral artery bypass system. With aortic clamping alone, ICP increased from 9.8 +/- 2.2 mm Hg to 15.2 +/- 2.8 mm Hg (p < 0.05). With passive shunting, ICP was decreased to 13.8 +/- 3.0 mm Hg, which was still significantly elevated above baseline. However, with active bypass, ICP remained at control level (9.8 +/- 2.2 mm Hg). Mean distal aortic pressure, which was 82 +/- 10 mm Hg in the control state, decreased to 20 +/- 0.5 mm Hg with clamping alone and to 39 +/- 9 mm Hg with passive shunting, whereas with active support, a distal pressure of 64 +/- 8 mm Hg was achieved. In contrast to passive shunting, active distal bypass results in maintenance of ICP at baseline levels and results in distal aortic pressure significantly greater than that achieved with either aortic clamping alone or passive shunting. Thus, active distal circulatory support produces the greatest salutary effect on the two determinants of the spinal cord perfusion pressure gradient: ICP and distal aortic pressure. This support modality may be the best adjunctive technique to maintain the spinal cord perfusion gradient and hence minimize the risk of ischemic injury.

Recombinant platelet factor 4 reversal of heparin in human cardiopulmonary bypass blood.

The ability of recombinant platelet factor 4, a protein of human origin with high heparin affinity, and the present clinical heparin reversal agent, protamine, to neutralize heparin in human whole blood was studied by means of three standard whole blood coagulation tests: whole blood clotting time, heparin assay, and activated clotting time. Ten subjects were chosen at random among patients undergoing cardiopulmonary bypass operations. Heparinized blood, free of protamine, was obtained from the bypass reservoir for testing. Whole blood aliquots, without reversal agents (controls) or with either protamine (10, 20, 30, or 40 micrograms/ml) or recombinant platelet factor 4 (10, 20, 40, or 80 micrograms/ml), were analyzed. The quantity of each agent required to reverse the ten samples, using 95% upper confidence bounds (t distribution) was determined for each method. Recombinant platelet factor 4 reversed heparin at 40 micrograms/ml and protamine at 20 micrograms/ml, suggesting a reversal ratio for recombinant platelet factor 4/protamine of 2:1 on a milligram basis. Further, currently available methods for testing coagulation should be reliable, without modification, to monitor the restoration of normal coagulation parameters with recombinant platelet factor 4 after cardiopulmonary bypass.