Fibrin glue for intraperitoneal laparoscopic mesh fixation: a comparative study in a swine model.

BACKGROUND: The classic method of mesh fixation in laparoscopic ventral hernia repair is transfascial sutures with tacks. This method has been associated with low recurrence rates, but yields significant morbidity from pain and bleeding. Fibrin glue has been used successfully in inguinal hernia repair with decreased incidence of chronic pain without an increase in recurrence rates, but its utility for laparoscopic ventral hernia repair is unknown. Our aim is to evaluate the efficacy of fibrin glue for laparoscopic mesh fixation to the anterior abdominal wall compared with other fixation methods. METHODS: Four different laparoscopic mesh fixation methods were randomly assigned to midline positions along the abdominal wall of 12 female pigs and compared: (1) fibrin glue only (GO), (2) transfascial sutures with tacks (ST), (3) fibrin glue with tacks (GT), and (4) tacks only (TO). At 4 weeks post implantation, tensile strength, adhesions, migration, contraction, and buckling/folding were assessed using Kruskal-Wallis one-way analysis by ranks test. RESULTS: There were no significant differences in tensile strength, adhesions or buckling/folding among the four fixation methods. A significant increase in mean migration (3.3 vs. 0.0 mm, p = 0.03) and percentage contraction (28% vs. 14%, p = 0.02) were identified in the GO group when compared with ST (see Table 3). CONCLUSIONS: Mesh fixation using fibrin glue has comparable tensile strength and adhesion rate to sutures with tacks in the swine model. Increased contraction and migration rates associated with fibrin glue alone may be an issue and warrants further study. On the other hand, the GT group showed similar biomechanical characteristics to the other groups and may represent a reasonable alternative to the use of transfascial sutures.

Laparoscopic versus open appendectomy for the obese patient: a subset analysis from a prospective, randomized, double-blind study.

BACKGROUND: The clinical outcomes for patients randomized to either open or laparoscopic appendectomy are comparable. However, it is not known whether this is true in the subset of the adult population with higher body mass indexes (BMIs). This study aimed to compare the outcomes of open versus laparoscopic appendectomy in the obese population. METHODS: A subgroup analysis of a randomized, prospective, double-blind study was conducted at a county academic medical center. Of the 217 randomized patients, 37 had a BMI of 30 kg/m(2) or higher. Open surgery was performed for 14 and laparoscopic surgery for 23 of these patients. The primary outcome measures were the postoperative complication rates. The secondary outcomes were operative time, length of hospital stay, time to resumption of diet, narcotic requirements, and Medical Outcomes Survey Short Form 36 (SF-36) quality-of-life data. RESULTS: No differences in complications between the open and laparoscopic groups were found. Also, no significant differences were seen in any of the secondary outcomes except for a longer operative time among the obese patients. CONCLUSIONS: In this study, laparoscopic appendectomy did not show a benefit over the open approach for obese patients with appendicitis.

Acute urinary retention in pediatric cerebral palsy: Is there an optimal management strategy?

INTRODUCTION AND OBJECTIVE: Cerebral palsy (CP) patients commonly have lower urinary tract dysfunction. Urinary retention (UR), which has been associated with dysfunctional voiding in CP can correlate to chronic upper tract dysfunction. We sought to provide insight into the pediatric presentation of acute UR in patients with CP and subsequent outcomes in this at-risk population. STUDY DESIGN: All children with perinatally acquired CP presenting to a regional health network were identified from 2009 to 2019. Retrospective analysis of a hospitalized subset concurrently diagnosed with a first episode of acute UR was performed. Factors associated with new-onset UR are described, as well as management. Using follow-up data, we also assessed the risk for recurrent UR and/or abnormal renal imaging after an initial UR presentation. RESULTS: 3404 CP patients were analyzed with only 33 fulfilling inclusion criteria. Median age was 10(IQR 7.5-16; range 1-22) years, 87.9% were GMFCS-V. 39.4% had a reported history of decreased urinary frequency. At presentation, median maximal time without void prior to catheterization was 13 h, and catheterized volume was a median 120% expected capacity-for-age. 84.8% of presentations were associated with a known transient/reversible etiology. 51.5% were post-anesthesia at median 3.5 days, 33.3% had associated constipation, 30.3% had received exacerbating medications. 11/33 were taught clean intermittent catheterization (CIC) after the initial presentation (all pro re nata [PRN] except one). At a median follow-up of 37 months: 50% of those without a CIC PRN no void plan had a repeat episode, at a median of 10.8 months later. Of the patients who had follow-up renal imaging at a median 22.0 months after presentation, 45% had abnormalities: 7 with debris or suspected stones and 2 with collecting system dilation. No factors associated with the initial UR presentation were found to be significantly predictive of recurrence or abnormal follow-up imaging. DISCUSSION: Patients with CP presenting with acute UR are often those with the most severe limitations and have a history of decreased urinary frequency. They usually have transient or reversible factors associated with UR presentation, however UR recurrence and abnormal imaging in this population subset is common. CONCLUSIONS: Pediatric patients with CP who present with acute UR usually present in the context of recent anesthesia and in the setting of exacerbating factors. They are at risk for recurrence and may be best managed with caretaker education of CIC PRN no void to address recurrent episodes. Providers should consider surveillance of these patients for the development of abnormal renal imaging.

Human Serum Modifies Aggregation Properties of Commonly Used Epidural Steroids.

BACKGROUND: Case reports of catastrophic neurological sequelae during ESIs have questioned the safety of this procedure. A proposed mechanism is particulate steroid embolization resulting in neuralischemia. Previous reports have described steroid clumping in common epidural injection mixtures. We demonstrate that physiologic medium can also modify aggregation. OBJECTIVE: To inspect and compare aggregative properties of steroid preparations with and without human serum. SETTING: Academic tertiary care center. HYPOTHESIS: Particulate steroids display different aggregation characteristics in serum compared to non-physiologic solutions. DESIGN: Solutions were inspected under light microscopy: betamethasone sodium phosphate/betamethasone acetate, methylprednisolone, and dexamethasone were each mixed in lidocaine 1%, bupivacaine 0.5%, or sterile water in a 1:1 ratio. All preparations were inspected under light microscopy with 100x and 400x magnifications by a pathologist blinded to our expectations and hypothesis. Five random viewing fields were selected within each slide and the number of aggregates per field and the number of particles per aggregate was evaluated. RESULTS: The addition of serum had a significant effect on steroid particle aggregation and number of particles per aggregate. LIMITATIONS: This study was limited by sample size as only 2 sets of human serum samples were tested with each preparation against one non-serum control. Additionally, as steroid preparations were evaluated under light microscopy, the ex vivo setting must be considered in the interpretation of results. Finally, mixing preparations with human serum as opposed to whole blood was necessary to allow for improved visibility on light microscopy despite the fact that whole blood may be necessary to more closely emulate in vivo coagulation setting. CONCLUSIONS: Overall, the presence of serum resulted in fewer large steroid particle aggregates when compared to non-serum control samples. Amongst particulate steroids, betamethasone with bupivacaine 0.5% demonstrated the fewest and smallest particle aggregates, suggesting that preparation may reduce the risk of embolic infarction. Methylprednisolone formed significantly larger particles in bupivicaine 0.5% with serum compared to non-serum controls.