Goal directed fluid therapy for major liver resection: A multicentre randomized controlled trial.

BACKGROUND: The effect a restrictive goal directed therapy (GDT) fluid protocol combined with an enhanced recovery after surgery (ERAS) programme on hospital stay for patients undergoing major liver resection is unknown. METHODS: We conducted a multicentre randomized controlled pilot trial evaluating whether a patient-specific, surgery-specific intraoperative restrictive fluid optimization algorithm would improve duration of hospital stay and reduce perioperative fluid related complications. RESULTS: Forty-eight participants were enrolled. The median (IQR) length of hospital stay was 7.0 days (7.0:8.0) days in the restrictive fluid optimization algorithm group (Restrict group) vs. 8.0 days (6.0:10.0) in the conventional care group (Conventional group) (Incidence rate ratio 0.85; 95% Confidence Interval 0.71:1.1; p = 0.17). No statistically significant difference in expected number of complications per patient between groups was identified (IRR 0.85; 95%CI: 0.45-1.60; p = 0.60). Patients in the Restrict group had lower intraoperative fluid balances: 808 mL (571:1565) vs. 1345 mL (900:1983) (p = 0.04) and received a lower volume of fluid per kg/hour intraoperatively: 4.3 mL/kg/hr (2.6:5.8) vs. 6.0 mL/kg/hr (4.2:7.6); p = 0.03. No significant differences in the proportion of patients who received vasoactive drugs intraoperatively (p = 0.56) was observed. CONCLUSION: In high-volume hepatobiliary surgical units, the addition of a fluid restrictive intraoperative cardiac output-guided algorithm, combined with a standard ERAS protocol did not significantly reduce length of hospital stay or fluid related complications. Our findings are hypothesis-generating and a larger confirmatory study may be justified.

Spinal accessory nerve transfer outperforms cervical root grafting for suprascapular nerve reconstruction in neonatal brachial plexus palsy.

BACKGROUND: The authors evaluated long-term shoulder function in patients with neonatal brachial plexus palsy undergoing suprascapular nerve reconstruction with cervical root grafting or spinal accessory nerve transfer. METHODS: A retrospective review was performed on all infants presenting with neonatal brachial plexus palsy between 1994 and 2010. Functional outcomes were compared by type of suprascapular nerve reconstruction. RESULTS: Seventy-four patients met the inclusion criteria (46 transfers, 28 grafts). Both groups presented with an active movement scale score of 2.0 for shoulder abduction and 0.0 for external rotation. Postoperative follow-up was 9.0 years for the graft group and 6.7 years for the transfer group. Both groups achieved an active movement scale score of 5.0 for shoulder abduction at 12, 24, and 36 months postoperatively. Active movement scale scores for shoulder external rotation were 1.0, 2.0, and 2.5 for the graft group versus 2.0, 2.0, and 3.0 for the transfer group at 12, 24, and 36 months postoperatively. None of these differences reached statistical significance. Composite Mallet scores were 13.0 for the graft group versus 15.0 for the transfer group at 3 years (p = 0.06) and 13.0 for the graft group versus 16.0 for the transfer group at 5 years postoperatively (p = 0.07). Secondary shoulder surgery was performed on 57.1 percent (16 of 28) of patients with grafts compared with 26.1 percent (12 of 46) of patients with transfers (OR, 3.17; p = 0.02). CONCLUSION: Suprascapular nerve reconstruction by cervical root grafting results in poorer shoulder function and a two-fold increase in secondary shoulder surgery compared with spinal accessory nerve transfer. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Three patterns of fronto-orbital remodeling for metopic synostosis: comparison of cranial growth outcomes.

BACKGROUND: The authors compared cranial growth across three patterns of fronto-orbital remodeling for metopic synostosis. METHODS: The authors reviewed all patients who underwent fronto-orbital remodeling for isolated metopic synostosis between 2006 and 2009. Inclusion criteria consisted of patients with preoperative, short-term postoperative (4 to 12 months), and long-term postoperative (>36 months) three-dimensional photographs. Patients were categorized by fronto-orbital remodeling pattern: group 1, retrocoronal; group 2, partial coronal; and group 3, precoronal. Head circumference, minimum frontal breadth (ft-ft), and maximum cranial length were measured by three-dimensional photographs, converted to standard Z scores, and compared. RESULTS: Thirty-one patients met inclusion criteria (group 1, n=12; group 2, n=10; and group 3, n=9). Group 1 presented with the greatest phenotypic severity. From preoperative to short-term postoperative assessment, head circumference Z scores rose for group 1 but dropped for groups 2 and 3, and the three groups demonstrated equivalent increases in minimum frontal breadth Z scores. From short-term to long-term postoperatively, the three groups demonstrated similar stability in head circumference Z scores but decreased minimum frontal breadth Z scores. From preoperatively to long-term postoperatively, head circumference Z scores rose for group 1 but fell for groups 2 and 3 (change in Z score, 0.5, -0.5, and -0.7, respectively; p=0.06) and the three groups demonstrated equivalent drops in minimum frontal breadth Z scores. Across preoperative to short-term postoperative and preoperative to long-term postoperative assessment, group 1 displayed the least drop in maximum cranial length Z scores. CONCLUSIONS: Retrocoronal patterns of fronto-orbital remodeling provide long-term gains in head circumference percentile and the least growth impairment in cranial length. Irrespective of osteotomy design, expansion in frontal breadth relapses significantly over time. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.