Anticipation of the difficult airway: preoperative airway assessment, an educational and quality improvement tool.

BACKGROUND: Assessment of the potentially difficult airway (DA) is a critical aspect of resident education. We investigated the impact of a new assessment form on airway prediction and management by anaesthesia residents. We hypothesized that residents would demonstrate improvement in evaluation of DAs over the study duration. METHODS: After IRB approval, anaesthesia residents were randomized into two groups: control (existing form) and experimental (new form). Data were collected prospectively from August 2008 to May 2010 on all non-obstetric adult patients undergoing non-emergent surgery. RESULTS: Eight thousand three hundred and sixty-four independent preoperative assessments were collected and 8075 were analysed. The experimental group had the higher completion rate than the control group (94.3% vs 84.3%, P=0.001). DA prediction was higher for the control group (71.2%) compared with the experimental group (69.1%; P=0.032). A significant improvement in prediction rates was found over time for the experimental group (likelihood estimate=0.00068, P=0.031). CONCLUSIONS: The use of a comprehensive airway assessment did not improve resident ability to predict a DA in an academic, tertiary-based hospital, anaesthesiology residency training programme.

[Response of interleukin-6 in patients undergoing a laparoscopic or laparotomic cholecystectomy]. / Risposta della interleukina-6 in pazienti sottoposti a colecistectomia laparoscopica o laparotomica.

BACKGROUND: It is well known that surgery induces an acute inflammatory response associated with significant increase of interleukin-6 (IL-6) and C reactive protein (CRP). Laparoscopic cholecystectomy (LC) is a so called "mini-invasive" surgical intervention and on the basis of this consideration it has been investigated if and how serological markers of inflammation are modified in patients after laparoscopic cholecystectomy compared to patients undergoing open cholecystectomy. METHODS: The acute phase of inflammation (IL-6, CRP and body temperature) was evaluated in 53 patients one day before surgery and p.o. after 1, 3 and 6 days; 26 patients underwent "open" cholecystectomy and 27 LC. RESULTS: One day after surgery patients with open cholecystectomy showed significant increase (p < 0.05) of IL-6, CRP and body temperature, while these parameters were almost unchanged in patients with LC. In patients with "open" cholecystectomy, 2 p.o. complications (pneumonia) were observed. CONCLUSIONS: In conclusion, LC, although it requires longer operative time, strongly reduces p.o. pain, hospitalization, promotes earlier recovery and return to normal activity, avoiding the acute phase of p.o. inflammation with better p.o. morbidity compared to open surgery.

Is laparoscopic cholecystectomy a safe alternative to open cholecystectomy for pediatric patients with cholelithiasis?

The results with five pediatric patients (6-15 years) who underwent laparoscopic cholecystectomy for symptomatic cholecystolithiasis are reported here. One patient had associated hematological disease (sickle-cell anemia). All five children were submitted to surgery using the laparoscopic technique. Intraoperative cholangiography was performed in two cases with uncertain ductal and vascular intraoperative anatomy. None of the operations was converted to open cholecystectomy, and there were no operative complications. The mean hospital stay was 2.2 days (range 2-3 days). All five children were able to return to normal activity within a week. No long-term complications were seen in any of the patients during an average follow-up period of 10.6 months (range 8-14). We believe that laparoscopic cholecystectomy in children is safe and effective, and that it is an important alternative to open cholecystectomy. However, prospective comparative studies of the procedure are necessary.

[Chronic abdominal pain: role of video-laparoscopic adhesiolysis]. / Il dolore addominale cronico: ruolo della adesiolisi videolaparoscopica.

Adhesions have been suggested as a possible cause of chronic abdominal pain, but the reports of their etiological role conflict. Lysis of adhesions has been proposed as the therapeutic modality of choice, although the reports of success are controversial. The aim our prospective study was to determine whether laparoscopic adhesiolysis ameliorates chronic abdominal pain in patients with abdominal adhesions. Forty-one patients with chronic abdominal pain lasting for more than 6 months, but with no abnormal findings other than adhesions found at laparoscopy, underwent laparoscopic adhesiolysis. 37 patients (90.2%) were available for follow-up after a median time interval of 18 months (range: 12-41 months). Twenty-two patients (59.4%) were free from abdominal pain and 9 (24.3%) patients reported significant amelioration of their pain. Six (16.2%) patients had no amelioration. In conclusion the laparoscopy is an effective tool for the evaluation of patients with chronic abdominal pain, and laparoscopic adhesiolysis cures of ameliorates chronic abdominal pain in more than 80% of patients.

[THe video laparoscopic experience of the general surgeon in cholecystectomy in childhood]. / L'esperienza videolaparoscopica del chirurgo generale nella colecistectomia in età pediatrica.

Despite the exponentially increasing number of laparoscopic cholecystectomies on adults to date, there is a paucity of reports in the literature about this new technique in pediatric patients. From September 1992 to February 1995, 140 patients underwent laparoscopic cholecystectomy. Since July 1993, in our institution, five pediatric patients (three females and two males) with a diagnosis of cholelithiasis underwent laparoscopic cholecystectomy. The age of the patients ranged from 6 to 15 years (mean 8.8 years) and they weighed 18-58 kg (mean 28.4 kg). All five patients had biliary cholic and ultrasound evidence of cholelithiasis. One patient had associated hematological disease (sickle cell disease). All 5 children were operated using the laparoscopic approach technique. Operative cholangiography was performed in cases with ductal and vascular intraoperative anatomy unclear. No operation was converted to open cholecystectomy. Intraoperative cholangiography was performed successfully (100%). The mean time of surgery was 50.2 minutes (range from 38 to 68). There were no operative complications. The mean hospital stay was 2.2 days (range 2 to 3 days). All five returned to their activity within a week. No long-term complications were seen in all patients throughout an average follow-up period of 10.6 months (range 8-14). The benefits of laparoscopic cholecystectomy in children are clear and obvious. It is safe and effective and should now be the treatment of choice for cholelithiasis in pediatric patients.

[Head trauma in a general surgery department: observations, diagnostic and therapeutic indications]. / Il trauma cranico in una divisione di chirurgia generale: osservazioni, indicazioni diagnostiche e terapeutiche.

UNLABELLED: The authors reviewed the records of 927 patients admitted to Surgical Clinic University of L'Aquila from November 1986 to July 1990 with head trauma. The 5.6% (52 patients) had skull fractures. 23 (2.4%) patients sustained significant intracranial sequelae from their injuries, but only 4 (17.3%) of these also sustained fractures, 17 did not. Of the four fractures 1 were simple, 2 was depressed and 1 was basilar. The patients (17) without a skull fracture and positive CT were transferred to a neurosurgical department, where 12 underwent operation. The patients (4) with a skull fracture and positive CT and 2 patients with a depressed skull fracture and negative CT were transferred to a neurosurgical department where 5 (except 1 patient with simple fracture) underwent operation. The severity of coma was evaluated according to Glasgow Coma Scale (G.C.S.). The 2.4% of patients had the Glasgow Coma Scale = or less than 7. The CT or MNR are indicate in the presence of neurologic abnormalities. Overall mortality rate was about 0.53%. In the severe head trauma (G.C.S. = or less than 7) was of 17,3. IN CONCLUSION: the skull radiography is not indicated of routine and are performed for the evaluation of depressed fractures, of fracture of the cranial base and of cervical vertebrae: the MNR was found to be superior to CT and to be very effective in the detection of traumatic head lesions: the Glasgow Coma Scale is important for monitoring, stratification and prognostic evaluation of patients.

[Experience with intrauterine contraception. Survey of 600 IUD users at the S. Anna University Hospital in Rome]. / Esperienze di contraccezione intrauterina. Rilievi su 600 utenti di IUD presso l'Ospedale Universitario S. Anna in Roma.

PIP: A group of 600 IUD users aged 26 to 35 were studied. 440 women were married; 434 were pluriparae and 166 nulliparae. 24 (5.5%) had undergone cesarean section, and 266 (44.3%) had had induced abortion. 23% of single women had opted for voluntary termination of pregnancy, while 72% had previous experience with IUDs or oral contraceptives. 273 (45.5%) relied on behavioral methods of contraception, 33 (5.5%) used the diaphragm, 279 (46.5%) used pills, 124 (20.6%) used condoms (50.6%) used ML-250 IUD, 144 (24%) used Progestasert, 87 (14.5%) used Gravigard, 42 (7%) used Minigravigard, 18 (3%) used Nova-T, 4 (0.6%) used Anticon, and 1 (0.1%) relied on No-Gravid. The IUD was removed prematurely in 119 cases, 339 were removed at the end of usefulness, dropout occurred in 51 cases, and expulsions in 14 cases. IUD failure was registered in 103 cases corresponding to 21.8% of the total. Bleeding caused 31 instances, 22 were due to dislocation, there were 15 intra -uterine pregnancies, 14 expulsions, 11 cases of pelvic pain, 4 cases of pelvic inflammatory disease, 3 cases of extrauterine pregnancy, and 3 other failures of IUDs. 31% of failures occurred in the 31-35 age group, and 40% of nulliparous women had IUD experience, but only 22.8% had a positive experience. 83.9% of those who used progesterone-containing pills had success with them, only 16.1% failed. Pluriparae over 30 used Progestasert most successfully. Nulliparous women did not represent the ideal candidates for IUD use, previous positive experience was an important element of success, while less important factors were age and abortion history.^ieng