Tension pneumocephalus following bariatric surgery: case report.

Bariatric surgery is an effective treatment for patients with idiopathic intracranial hypertension (IIH), a condition that is associated with skull base defects. A 55-year-old woman presented with symptoms of intractable nausea and vomiting, followed by headache and confusion two weeks after an elective laparoscopic vertical sleeve gastrectomy procedure. She had a presumed diagnosis of IIH and a remote history of CSF oto/rhinorrhea treated with a lumbar peritoneal (LP) shunt. Computed tomography (CT) scan of the head revealed tension pneumocephalus with midline shift and dehiscence of the tegmen. The patient underwent emergent craniotomy for decompression of the air-filled temporal lobe, clamping of the LP shunt, and repair of the skull base defect. Caution should be exercised in obese patients with a history of CSF leak secondary to a middle fossa skull base defect when being evaluated for bariatric surgery.

Acceleration of diabetic wound healing with adipose-derived stem cells, endothelial-differentiated stem cells, and topical conditioned medium therapy in a swine model.

OBJECTIVE: The purpose of our study was to investigate the effect of adipose-derived stem cells (ASCs), endothelial-differentiated ASCs (EC/ASCs), and various conditioned media (CM) on wound healing in a diabetic swine model. We hypothesized that ASC-based therapies would accelerate wound healing. METHODS: Diabetes was induced in four Yorkshire swine through intravenous injection of streptozotocin. ASCs were harvested from flank fat and cultured in either M199 or EGM-2 medium. A duplicate series of seven full-thickness dorsal wounds were surgically created on each swine. The wounds in the cellular treatment group underwent injection of low-dose or high-dose ASCs or EC/ASCs on day 0, with a repeat injection of one half of the initial dose on day 15. Wounds assigned to the topical CM therapy were covered with 2 mL of either serum-free M199 primed by ASCs or human umbilical vein endothelial cells every 3 days. Wounds were assessed at day 0, 10, 15, 20, and 28. The swine were sacrificed on day 28. ImageJ software was used to evaluate the percentage of wound healing. The wounded skin underwent histologic, reverse transcription polymerase chain reaction, and enzyme-linked immunosorbent assay examinations to evaluate markers of angiogenesis and inflammation. RESULTS: We found an increase in the percentage of wound closure rates in cell-based treatments and topical therapies at various points compared with the untreated control wounds (P < .05). The results from the histologic, messenger RNA, and protein analyses suggested the treated wounds displayed increased angiogenesis and a diminished inflammatory response. CONCLUSIONS: Cellular therapy with ASCs, EC/ASCs, and topical CM accelerated diabetic wound healing in the swine model. Enhanced angiogenesis and immunomodulation might be key contributors to this process.

Acute kidney injury following implementation of an enhanced recovery after surgery (ERAS) protocol in colorectal surgery.

PURPOSE: Fluid management within Enhanced Recovery After Surgery (ERAS) protocols is designed to maintain a euvolemic state avoiding the negative sequelae of hypervolemia or hypovolemia. We sought to determine the effect of a recent ERAS protocol implementation on kidney function and on the incidence of postoperative acute kidney injury (AKI). METHODS: A total of 132 elective colorectal resections performed using our ERAS protocol were compared to a propensity-matched group prior to ERAS implementation. Fluid balance, urine output, creatinine, and blood urea nitrogen (BUN) were recorded for all patients, and the incidence of AKI was determined according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. RESULTS: Implementation of our ERAS protocol decreased average postoperative length of hospital stay (5.5 vs 7.7 days, p < 0.0001) and time to return of bowel function (2.5 vs 4.1 days, p < 0.0001). The rate of postoperative AKI increased following implementation of the protocol (11.4 vs 2.3%, p < 0.0001). However, by the time of discharge, the average creatinine of ERAS patients who had experienced AKI had returned to their preoperative baseline values (p = 0.9037). Significant univariate predictors of AKI in ERAS patients were longer operative times (p < 0.01) and the diagnosis of diverticulitis (p < 0.01). Within our ERAS patients, AKI was associated with a prolonged postoperative length of hospital stay (p < 0.01). CONCLUSIONS: Despite the proven benefits of the Enhanced Recovery After Surgery (ERAS) protocols, care should be taken during protocol implementation to monitor for and to prevent acute kidney injury.

The Effect of the Histone Deacetylase Inhibitor Suberoylanilide Hydroxamic Acid and Paclitaxel Treatment on Full-Thickness Wound Healing in Mice.

INTRODUCTION: Neoadjuvant chemotherapy prior to lumpectomy or mastectomy for breast cancer challenges wound healing. Suberoylanilide hydroxamic acid (SAHA), a histone deacetylase inhibitor, has been shown to work synergistically with paclitaxel in vitro and in preclinical studies. In addition, our laboratory has demonstrated that SAHA treatment decreases paclitaxel-associated stem cell toxicity, modulates inflammatory response, and promotes wound healing in injured fibroblast cells. Our goal was to determine if combined SAHA and paclitaxel treatment would improve wound healing in an in vivo full-thickness murine model, without altering antitumor effect. METHODS: Thirty-two nude athymic mice received intraperitoneal injections of paclitaxel (20 mg/kg), SAHA (25 mg/kg), paclitaxel + SAHA (20 mg/kg + 25 mg/kg), or no treatment for 2 weeks prior to surgery. Under general anesthesia, 8-mm full-thickness dorsal wounds were created in all animals, and a silicone splint was attached to minimize wound contraction. The wounds were measured twice a week with a surgical caliper until healing was complete. To evaluate the in vivo effect of drug treatment, 16 athymic nude mice with MDA-MB-231 xenografts received the treatments described previously, following which tumor volumes were compared between groups. RESULTS: Average wound healing time was prolonged in mice treated with paclitaxel (20 ± 1.9 days), and combination SAHA + paclitaxel therapy improved average wound healing time (17.0 ± 1.8 days). In the xenograft model, the antitumor effect of SAHA and paclitaxel (average tumor volume 43.9 ± 34.1 mm) was greater than paclitaxel alone (105.8 ± 73.8 mm). CONCLUSIONS: The addition of SAHA to taxane chemotherapy improves the therapeutic effect on triple-negative breast cancer while decreasing the detrimental effect of paclitaxel on wound healing. This may have substantial implications on improving outcomes in breast reconstruction following chemotherapy.

Oral Versus Intravenous Acetaminophen within an Enhanced Recovery after Surgery Protocol in Colorectal Surgery.

BACKGROUND: Multimodal pain management within enhanced recovery after surgery (ERAS) protocols is designed to decrease opioid use, promote mobilization, and decrease postoperative complications. OBJECTIVES: To evaluate the role of intravenous (IV) versus oral (PO) acetaminophen within an established ERAS protocol in colorectal surgery. STUDY DESIGN: This was a retrospective observational study. SETTING: This research took place within an established perioperative colorectal surgery protocol. METHODS: A total of 91 consecutive elective colorectal resections performed according to an ERAS protocol using only IV acetaminophen (IV group) were compared with 84 consecutive resections performed using one dose of IV acetaminophen followed by subsequent administration of oral acetaminophen (PO group). Our multimodal pain management strategy also included transverse abdominis plane blocks, celecoxib, and ketorolac medications for both groups. Opioid requirements, maximum and average daily pain scores by the Visual Analog Scale, and postoperative outcomes were compared between groups. RESULTS: There were no differences in maximum or average pain scores on postoperative days 0-3 or at time of discharge between IV and PO groups. Compared with the IV acetaminophen only group, the PO group received significantly more perioperative opioids through 72 hours postoperatively (68.8 oral morphine equivalents [OME] IV group vs. 93.7 OME PO group; P < 0.0001), were more likely to require opioid patient-controlled analgesia (8.9% IV group vs. 46.4% PO group; P < 0.0001), and were more likely to experience postoperative nausea and vomiting (33.0% IV group vs. 48.8% PO group; P = 0.0449). LIMITATIONS: Significant limitations include the studies' retrospective nature and that it was performed at a single institution. CONCLUSIONS: Restriction of IV acetaminophen within an ERAS protocol in colorectal surgery was associated with increased opioid use, greater need for opioid patient-controlled analgesia, and increased incidence of postoperative nausea and vomiting. IV acetaminophen may be superior to oral acetaminophen in the early postoperative setting. KEY WORDS: Perioperative pain management, enhanced recovery after surgery, acetaminophen, multimodal pain control, nonopioid.