Does hydrogen peroxide application to the dermis following surgical incision affect Cutibacterium acnes cultures in total shoulder arthroplasty in male patients? A randomized controlled trial.

BACKGROUND: Periprosthetic joint infections occur in 1%-4% of primary total shoulder arthroplasties (TSAs). Cutibacterium acnes is the most commonly implicated organism and has been shown to persist in the dermis despite use of preoperative antibiotics and standard skin preparations. Studies have shown decreased rates of cultures positive for C acnes with use of preoperative benzoyl peroxide or hydrogen peroxide (H2O2), but even with this positive deep cultures remain common. We sought to determine whether an additional application of H2O2 directly to the dermis following skin incision would further decrease deep culture positivity rates. METHODS: We performed a randomized controlled trial comparing tissue culture results in primary TSA in patients who received a standard skin preparation with H2O2, ethanol, and ChloraPrep (CareFusion, Leawood, KS, USA) vs. an additional application of H2O2 to the dermis immediately after skin incision. Given the sexual dimorphism seen in the shoulder microbiome regarding C acnes colonization rates, only male patients were included. Bivariable and multivariable analyses were performed to compare rates of positive cultures based on demographic and surgical factors. RESULTS: Dermal cultures were found to be positive for C acnes at similar rates between the experimental and control cohorts for the initial (22% vs. 28%, P = .600) and final (61% vs. 50%, P > .999) dermal swabs. On bivariable analysis, the rate of positive deep cultures for C acnes was lower in the experimental group, but this difference was not statistically significant (28% vs. 44%, P = .130). However, patients who underwent anatomic TSA were found to have a significantly greater rate of deep cultures positive for C acnes (57% vs. 28%, P = .048); when controlling for this on multivariable analysis, the experimental cohort was found to be associated with significantly lower odds of having positive deep cultures (odds ratio, 0.37 [95% confidence interval, 0.16-0.90], P = .023). There were no wound complications in either cohort. CONCLUSIONS: An additional H2O2 application directly to the dermis following skin incision resulted in a small but statistically significant decrease in the odds of having deep cultures positive for C acnes without any obvious adverse effects on wound healing. Given its cost-effectiveness, use of a post-incisional dermal decontamination protocol may be considered as an adjuvant to preoperative use of benzoyl peroxide or H2O2 to decrease C acnes contamination.

Influence of glenoid wear pattern on glenoid component placement accuracy in shoulder arthroplasty.

BACKGROUND: Accurate glenoid component placement in shoulder arthroplasty is often difficult even with the use of preoperative planning. Computer navigation and patient-specific guides increase component placement accuracy, but which patients benefit most is unknown. Our purpose was to assess surgeons' accuracy in placing a glenoid component in vivo using 3-dimensional preoperative planning and standard instruments among various glenoid wear patterns. METHODS: We conducted a retrospective review of 170 primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) performed at a single institution. Commercially available preoperative planning software was used in all arthroplasties with multiplanar 2-dimensional computed tomography and a 3-dimensional implant overlay. After registration of intraoperative bony landmarks to the navigation system, participating surgeons with knowledge of the preoperative plan were blinded to the computer screen and attempted to implement their preoperative plan by simulating placement of a central-axis glenoid guide pin. Two hundred thirty-three screenshots of surgeon's simulated guide pin placement were included. Glenoid displacement, error in version and inclination, and overall malposition from the preoperatively planned target point were stratified by posterior wear status (with [Walch B2 or B3] or without [A1, A2, or B1]) and Walch classification (A1, A2, B1, B2, or B3). The glenoid component was considered malpositioned when version or inclination errors exceeded 10° or the starting point displacement exceeded 4 mm. RESULTS: For rTSA, errors in version were greater for glenoids with posterior wear compared with those without (8.1° ± 5.6° vs. 4.7° ± 4.0°; P < .001). On post hoc analysis, B2 glenoids had greater version error than A1, A2, and B1 glenoids. A greater proportion of glenoids undergoing rTSA that possessed posterior wear had an error in version >10° compared with those without (31% vs. 8%; P < .001). Consequently, glenoids undergoing rTSA with posterior wear were malpositioned at a greater rate compared with those without (73% vs. 53%). In contrast, glenoids undergoing aTSA with and without posterior wear did not differ based on displacement error, version error, inclination error, or malposition occurrence. CONCLUSIONS: Posterior glenoid bone loss more commonly resulted in glenoid version errors exceeding 10 degrees and component malposition in rTSA, but not for aTSA. Malposition was still relatively high in patients without significant posterior wear for both aTSA (36%) and rTSA (53%). Surgeons should consider alternate techniques beyond preoperative planning and standard instrumentation when performing shoulder arthroplasty in patients with posteriorly worn glenoids.

An audit to determine if vitamin b12 supplementation is necessary after sleeve gastrectomy.

ABSTRACT: Sleeve gastrectomy has increased in popularity over the last five years and it is likely to supersede gastric banding. Nevertheless, it is unclear whether vitamin B12 supplementation is required after surgery. The aim of this short report is to identify any vitamin B12 deficiency and highlight the necessity of post laparoscopic sleeve gastrectomy vitamin B12 monitoring. PATIENTS AND METHODS: A review of 66 patients underwent LSG in our institution. 25 patients were excluded as they had no postoperative vitamin B12 screening. 41 patients were included as screened for vitamin B12 and other micronutrients including selenium, serum folate, ferritin, iron, zinc, copper, magnesium and vitamin D. RESULT: There were 5 male (12%) and 36 females (88%), 8/41 patients (20%) had Vitamin B12 deficiency, none of them developed macrocytic anaemia. 17/21 (81%) patient were vitamin D deficient and 9/21 (43%) exhibited low selenium. CONCLUSION: In this small group, a 20% prevalence of vitamin B12 was identified. As a consequence vitamin B12 monitoring and supplementation will be a standard of care in the early postoperative period after LSG at this institution.

Evaluation of nurse-led discharge following laparoscopic surgery.

INTRODUCTION: The United Kingdom's Department of Health has identified reducing delays in patient discharge as a key aim for Health Service development. Laparoscopic cholecystectomy and laparoscopic inguinal hernia repair may be safely performed on a short stay basis, but day case rates remain low, with delays in discharge identified as a major contributing factor. Nurse-led discharge has been widely advocated to speed patient discharge across varied specialities, but objective evidence to support its use is lacking. This study aimed to assess the effectiveness of nurse-led discharge following laparoscopic surgery. METHODS: A retrospective comparison of doctor-led and nurse-led discharge following laparoscopic surgery was performed by analysis of two consecutive 4-month periods, prior to and following the introduction of nurse-led discharge by a laparoscopic nurse specialist. Outcomes assessed included time to discharge, reasons for delayed discharge, hospital readmissions and primary care episodes following discharge. RESULTS: A total of 128 patients were included in the study, with each discharge group containing 64 patients. Patients in the nurse-led discharge group were significantly more likely to be discharged on the day of surgery than patients in the doctor-led discharge group (17.2% vs. 4.7%; P = 0.023), with a highly significant difference in same day discharge rates noted among patients operated on during morning theatre lists (44.0% vs. 10.7%; P = 0.006). There was no significant difference between the discharge groups in readmission rates or in the number of patients seeking primary care attention following discharge. CONCLUSIONS: Nurse-led discharge may speed discharge following laparoscopic surgery with no apparent detriment to patient care.

Management of esophageal perforation and anastomotic leak by transluminal drainage.

INTRODUCTION: The management of esophageal perforations and leaks remains a challenge. Although there are broad management principles, each situation may require a different surgical approach. The aim of this report was to describe the management of these esophageal crises by transluminal drainage via a transabdominal approach. METHODS: Between 2005 and 2009, patients with anastomotic or gastric staple line leak (n = 4) or esophageal perforation (n = 2) underwent transabdominal surgery and transluminal drainage. This simple technique has, to the best of our knowledge, not been previously reported. RESULTS: All six patients survived. The median intensive care unit and hospital stays were 12 days (range 0-32) and 63 days (range 32-99), respectively. At a median follow-up time of 25 months (range 15-60), five of the six patients remain alive and well. One patient with node positive esophageal carcinoma has died from relapsed disease. CONCLUSIONS: Transabdominal transluminal drainage should be added to the list of potential techniques that can be employed in management of esophageal leaks and perforations. It is a valuable adjunct to the armamentarium of the esophageal surgeon for dealing with these challenging situations.

A simple, safe technique for the drainage of pancreatic pseudocysts.

BACKGROUND: A number of methods are available for the drainage of pancreatic pseudocysts, including percutaneous, endoscopic and open approaches. In Leicester, we developed a combined radiological and endoscopic technique (predating the use of endoscopic/ultrasound) to allow drainage of pancreatic pseudocysts into the stomach. The aim of the study was to evaluate the long-term results of this approach. METHODS: This is a retrospective study of patients undergoing combined endoscopic/ultrasound-guided percutaneous stenting between 1994 and 2007. Data were extracted from case records and our computerised radiology database. RESULTS: Thirty-seven combined endoscopic/ultrasound-guided procedures were undertaken. Median patient age was 52 years (range 26-84 years). Nineteen pseudocysts were secondary to acute pancreatitis and 18 were in patients with chronic pancreatitis. The diameter of pseudocysts on pre-procedure imaging ranged from 4 to 21 cm (median 11 cm). Median duration of hospital stay was 7 days (range 1-44 days) and 30-day mortality was 0%. Stents were inserted in 70.3% of patients (n= 26). Of those patients stented during the combined procedure, three developed infection of the pseudocyst, necessitating open cystgastrostomy within the first month. During a mean follow-up period of 41 months, two patients developed recurrent pseudocysts which were successfully drained with a further combined procedure (16 and 43 months). Repeat imaging in the remainder of patients failed to show any evidence of a persistent or recurrent pseudocyst beyond 2 months. CONCLUSION: Combined radiological and endoscopic drainage is safe, cost-effective and highly efficient in preventing recurrent pseudocyst formation.

Comparison of oncological outcomes after laparoscopic transhiatal and open esophagectomy for T1 esophageal adenocarcinoma.

INTRODUCTION: This study compared pathological characteristics and patterns of disease recurrence for patients with pT1 esophageal adenocarcinoma treated with either laparoscopic transhiatal esophagectomy or open esophagectomy. METHODS: From January 2000-December 2006, 44 patients had pT1 esophageal adenocarcinoma after esophagectomy. No patients had neoadjuvant treatment. Twenty-four patients had an Ivor Lewis operation, 4 had an open transhiatal and 16 had a laparoscopic transhiatal operation. RESULTS: There were 37 men. The median age was 64 years (range 35-80 years). Median lymph node yield was 19 (10-51) after an Ivor Lewis operation, 16 (3-28) after an open transhiatal operation and 15 (4-41) after a laparoscopic transhiatal operation. There were two in-hospital deaths (5%), both following open Ivor Lewis operation. All patients in the laparoscopic group had N0 disease; none received adjuvant treatment. Two patients (7%) in the open group had N1 disease, of whom one patient received adjuvant chemotherapy. Eleven patients had submucosal invasion. Alive patients had median follow-up of 36 months (range 5-87 months). One patient in the laparoscopic group had recurrence at 22 months. This patient had poorly differentiated N0 disease which was limited to the mucosa and died at 24 months. Two patients in the open group developed recurrence, at 6 months (N0 disease with submucosal invasion) and 8 months (N1 disease with submucosal invasion) and died at 7 and 14 months, respectively. Both patients had poorly differentiated tumours. The second patient with N1 disease is alive and well at 14 months. Estimated survival (Kaplan-Meier) at 3 years was 93%. CONCLUSIONS: As compared with open transthoracic esophagectomy, there is no oncological detriment in the treatment of pT1 esophageal adenocarcinoma by laparoscopic transhiatal esophagectomy. The incidence of recurrence is small (7%) but can occur even in patients with tumour limited to the mucosa or N0 disease.

Laparoscopic inguinal ligament tenotomy and mesh reinforcement of the anterior abdominal wall: a new approach for the management of chronic groin pain.

BACKGROUND: Chronic groin pain has an incidence of up to 6.2% and is common in people undertaking regular sports activity. A variety of surgical options exist for unresolving pain, which consist, for the most part, of a repair of the posterior abdominal wall, with or without mesh placement. We describe a new technique, which combines laparoscopic inguinal ligament tenotomy in conjunction with a mesh repair. METHODS: A retrospective analysis of the notes of 48 patients was undertaken in conjunction with a mailed questionnaire. Success of surgery was judged on return to preinjury sporting activity, severity of pain scores, frequency of pain scores, and functional limitation scores. RESULTS: There were no major complications associated with the procedure. Severity of pain, frequency of pain, and functional limitation scores were all significantly improved after surgery (P=0.0012, <0.0001, and <0.0001, respectively). Ninety-two percent of patients polled returned to normal sports activity after their surgery (n=24). The median return to strenuous sports activity was 28 days (range of 14 to 40 d). CONCLUSIONS: The success rates of laparoscopic tenotomy and mesh repair are comparable with the published literature and a lower median time interval before returning to preinjury sporting activity.

Survival following curative resection for pancreatic ductal adenocarcinoma. A systematic review of the literature.

CONTEXT: Patients with resectable pancreatic cancer comprise a small subgroup of the overall population with the disease from around 15 to 20%, with nearly all patients dying from their disease within 7 years of surgery. In the light of such bleak statistics, data regarding what factors may influence outcome, following attempted curative resection is essential in order to optimise the treatment options for patients. METHODS: This review analysed all English-language publications using PubMed and Web of Science databases for studies detailing outcomes following resection for pancreatic ductal adenocarcinoma from 1980 to the present day. MAIN OUTCOME MEASURES: The data examined from papers were post-operative mortality rates, median survival, yearly survival rates and other factors which may have influenced long-term survival; such as patient demographics, operative details and tumour characteristics (such as example tumour size, lymph node metastases and tumour differentiation). RESULTS: There has been significant improvement in post-operative mortality over the last decades with a modest improvement in long-term survival. With the exception of post-operative blood transfusion, tumour characteristics remain the only significant features influencing survival after pancreatic cancer surgery. Favourable prognostic factors include tumour size less than 2 cm, negative resection margin, lymph node negative tumours, well-differentiated tumours and absence of perineural or blood vessel invasion. CONCLUSION: In light of these data, it could be reasoned that tumour size, on cross-sectional imaging, might be employed as means of selecting the most appropriate candidates for surgery, in cases where the risks of resection are high.

Expression of nuclear Notch3 in pancreatic adenocarcinomas is associated with adverse clinical features, and correlates with the expression of STAT3 and phosphorylated Akt.

BACKGROUND AND OBJECTIVES: Reactivation of the Notch signalling pathway occurs in a range of human malignancies. Previous research suggests that Notch3 is expressed in pancreatic adenocarcinomas, but neither cellular location nor association with clinical parameters has been described. The relationship between Notch3, clinical endpoints, and other proteins with potential to interact with Notch was therefore examined. METHODS: An immunohistochemical study was performed on human pancreatic adenocarcinoma (n = 23) and normal pancreas (n = 12), to assess expression of Notch3, cyclin D1, pAkt, STAT3 and pSTAT3. Immunohistochemical data were then correlated with clinicopathological characteristics. RESULTS: Notch3 was significantly overexpressed in the cytoplasm of 73.9% of tumours. Nuclear expression was not observed in normal pancreatic ductal tissue, but was noted in 43.5% of tumours. No tumour expressing nuclear Notch3 was resectable. There were significant correlations between expression and intracellular location of Notch3 and each of STAT3, pSTAT3 and pAkt, but not cyclin D1. CONCLUSION: The presence of Notch3 in tumour nuclei is likely to represent functional activation of the protein, and is clearly linked to a more aggressive tumour phenotype. The correlation with STAT3, pSTAT3 and pAkt expression has not previously been described and the concurrent intracellular localisation of these proteins suggests a functional relationship between them.

Early warning scores predict outcome in acute pancreatitis.

The Early Warning Score (EWS) is a widely used general scoring system to monitor patient progress with a varying score of 0-20 in critically unwell patients. This study evaluated the EWS system compared with other established scoring systems in patients with acute pancreatitis. EWS scores were compared with APACHE scores, Imrie scores, computed tomography grading scores, and Ranson criteria for 110 admissions with acute pancreatitis. A favorable outcome was considered to be survival without intensive therapy unit admission or surgery. Nonsurvivors, necrosectomy, and critical care admission were considered adverse outcomes. EWS was the best predictor of adverse outcome in the first 24 hours of admission (receiver operating curve, 0.768). The most accurate predictor of mortality overall was EWS on day 3 of admission (receiver operating curve, 0.920). EWS correlated with duration of intensive therapy unit stay and number of ventilated days (P < 0.05) and selected those who went on to develop pancreas-specific complications such as pseudocyst or ascites. EWS of 3 or above is an indicator of adverse outcome in patients with acute pancreatitis. EWS can accurately and reliably select both patients with severe acute pancreatitis and those at risk of local complications.

Expression of thrombospondin-1 in resected colorectal liver metastases predicts poor prognosis.

PURPOSE: The aim of this study was to examine the expression and prognostic relevance of thrombospondin-1 (TSP-1) in tumor biopsies taken from a consecutive series of liver resections done at the University Hospitals of Leicester and the Royal Liverpool Hospital. EXPERIMENTAL DESIGN: Patients having undergone a liver resection for colorectal liver metastases at our institutions between 1993 and 1999 inclusive were eligible. Inclusion criteria were curative intent, sufficient tumor biopsy, and patient follow-up data. One hundred eighty-two patients were considered in this study. Standard immunohistochemical techniques were used to study the expression of TSP-1 in 5-microm tumor sections from paraffin-embedded tissue blocks. TSP-1 was correlated with survival using the Kaplan-Meier method and log-rank test for univariate analysis and the Cox proportional hazard model for multivariate analysis. RESULTS: One hundred eighty-two patients (male, n = 122 and female, n = 60) ages between 25 and 81 years (mean, 61 years) were included. TSP-1 was expressed around blood vessels (n = 45, 25%) or in the stroma (n = 59, 33%). No expression was detected in the remaining tumors. TSP-1 significantly correlated with poor survival on univariate (P = 0.01 for perivascular expression and P = 0.03 for stromal expression) and multivariate analysis (P = 0.01 for perivascular expression). CONCLUSION: TSP-1 is a negatively prognostic factor for survival in resected colorectal liver metastases.

Isolated Roux-loop pancreaticojejunostomy: a series of 61 patients with zero postoperative pancreaticoenteric leaks.

There have been approximately 70 reported variations of reconstruction after pancreaticoduodenectomy (PD). The pancreaticojejunal (PJ) anastomosis is the source of most reported morbidity and mortality. In this study, we aimed to identify the anastomotic leak rate in patients undergoing PD for malignant disease using a proximal isolated jejunal pancreatic anastomosis. Sixty-one consecutive patients undergoing PD (26 women and 35 men; age range, 41-79 years, mean age, 62 years). had an identical reconstruction. The PJ anastomosis was performed using the most proximal isolated jejunum in two layers: interrupted 4.0 Prolene was used to achieve mucosal/ductal continuity, and 3.0 Prolene was used for the serosal/parenchymal anastomosis, around an appropriately sized stent. All postoperative complications were recorded. A pancreatic leak was defined as persistent discharge of amylase-rich pancreatic drain fluid. The overall complication rate was 44% (27 of 61, including 15 chest infections, 8 wound infections, and 2 postoperative cardiac arrhythmias). There were 3 deaths (30-day mortality rate, 5%). One patient died after a cerebrovascular accident, one from respiratory failure secondary to pneumonia, and the third of methicillin-resistant Staphylococcus aureus septicemia after small bowel ischemia caused by pressure necrosis from a drain. There were no PJ anastomotic leaks. This method of pancreatojejunostomy has produced a 0% leak rate in this center.

Case of duodenal haematoma treated with ultrasound guided drainage.

Duodenal haematoma usually occurs secondary to blunt abdominal trauma(1), although more recently it has been recognized as a complication of endoscopic duodenal biopsy(2). The two established management strategies are to treat conservatively until resolution of the haematoma occurs or to surgically evacuate the haematoma. We present a case of duodenal haematoma that was successfully treated by ultrasound guided drainage when no improvement occurred with conservative treatment.

Microvessel density at presentation predicts subsequent muscle invasion in superficial bladder cancer.

PURPOSE: The purpose of this study was to determine whether angiogenesis, as measured by microvessel density (MVD), at presentation is related to subsequent progression of superficial bladder cancer (SBC). EXPERIMENTAL DESIGN: Archived primary bladder tumors from 180 patients were stained with a monoclonal antibody against cluster determinant 34 to label vessels. Image analysis was used to count MVD in 30 randomly selected areas in each case. RESULTS: Of the 170 patients evaluated, 37 progressed to muscle invasive disease. A strong association was found between the intensity of angiogenesis and clinical stage, pT1 tumors having a higher MVD than pTa disease. The median MVD was significantly higher at presentation in those patients that subsequently developed progressive SBC than in those that did not progress (P < 0.0001). pT1 (P = 0.001), grade 3 disease (P = 0.002), and MVD (P = 0.008) were found to predict subsequent disease progression on univariable analysis. Both MVD (P = 0.007) and pT1 disease (P = 0.044) remained significant predictive factors for subsequent disease progression on multivariable analysis. CONCLUSION: MVD in SBC at presentation is significantly higher in those cases that subsequently progress to muscle invasive disease.