Fetal heart rate mirrors maternal temperature during posterior fossa craniotomy: a case report.

While it is well known that maternal temperature affects fetal heart rate, the exact relationship is not well described. The circumstances accompanying most cases of maternal hypothermia and rewarming (e.g. a drowning event) have precluded a precise quantitative description of this relationship. We describe hypothermia and controlled rewarming during resection of a maternal brain stem tumor in the early third trimester. Continuous electronic fetal heart rate and core temperature monitoring demonstrated a near linear relationship during the development of hypothermia and rewarming. Recognition of the close relationship between maternal temperature and fetal heart rate can help safeguard maternal and fetal health, and prevent unnecessary delivery during non-obstetric surgery in pregnancy.

Combined percutaneous-endoscopic stenting of malignant biliary obstruction: results from 106 consecutive procedures and identification of factors associated with adverse outcome.

BACKGROUND: In patients in whom attempted endoscopic stenting of malignant biliary obstruction fails, combined percutaneous-endoscopic stenting and percutaneous stenting using expandable metallic endoprostheses offer alternative approaches to biliary drainage. Despite the popularity of the percutaneous route, there is no available evidence to support its superiority over combined stenting in this patient group. The objective of this study was to present the short- and long-term results of a large series of combined percutaneous-endoscopic stenting procedures and identify factors associated with adverse outcome. METHODS: Data were retrospectively collected on patients undergoing combined percutaneous-endoscopic biliary stenting for malignant biliary obstruction between January 2002 and December 2006. Short- and long-term outcomes were recorded, and pre-procedure variables correlated with adverse outcome. RESULTS: Combined biliary stenting was technically successful in 102 (96.2%) of 106 patients. Procedure-associated mortality rate was 0%. In-hospital morbidity and mortality rates were 24.5% and 16.7%, respectively, with the majority of deaths resulting from biliary sepsis. Median survival was 100 days, with a 13.7% stent occlusion rate. On multivariable analysis, baseline American Society of Anaesthesiologists (ASA) grade, decreasing serum albumin and increasing leucocyte count were independently associated with in-hospital mortality following combined stenting. CONCLUSION: Combined biliary stenting is associated with short- and long-term outcomes equal to those reported in recent series of percutaneous transhepatic stenting. Randomised control trials, including cost-effectiveness analyses, are required to further compare these techniques. Outcomes following combined stenting may be further improved by early recognition and treatment of sepsis and scrupulous management of co-morbid disease.

The inguinal release procedure for groin pain: initial experience in 73 sportsmen/women.

OBJECTIVE: To assess the impact of the laparoscopic inguinal release procedure with mesh reinforcement on athletes with groin pain. DESIGN: Prospective cohort study. SETTING: Private sector. PATIENTS: Professional and amateur sportsmen/women undergoing the inguinal release for groin pain. MAIN OUTCOME MEASUREMENTS: Change in patient's symptoms, functional limitation and time to resuming sporting activity following surgery. RESULTS: 73 sportsmen/women underwent laparoscopic inguinal release in the study period, 37 (51%) of whom were professionals. 95% were male with a median age of 30 years. Following operation, patients returned to light training at a median of 1 week, full training at 3 weeks (professionals-2 weeks) and playing competitively at 4 weeks (professionals-3 weeks). 74% considered themselves match-fit by 4 weeks (84% of professionals). Following surgery, there was a highly significant improvement in frequency of pain, severity of pain and functional limitation in both the whole cohort and professional group. 88% reported a return to full fitness at follow-up, with 73% reporting complete absence of symptoms. 97% of the cohort thought the operation had improved their symptoms. CONCLUSIONS: This study shows that the laparoscopic inguinal release procedure may be effective in the treatment of a subgroup of athletes with groin pain.

A case of toxic megacolon in a patient with collagenous colitis.

Collagenous colitis is an uncommon inflammatory bowel disease, the aetiology of which is unknown. We report a case of toxic megacolon in a patient with collagenous colitis, a previously unreported complication.

Tumour characteristics predictive of survival following resection for ductal adenocarcinoma of the head of pancreas.

AIMS: We have maintained a highly conservative policy in selecting patients with carcinoma of the head of pancreas for resection. This has been based on tumour size, evidence of lymph node involvement or local invasion outside of the gland at laparotomy, laparoscopy or CT imaging. This study investigated our survival rates following pancreatic resection and examined clinicopathological predictors of survival. METHODS: Sixty-two consecutive patients undergoing pancreatic resections for malignancy were identified from 1999 onwards. Thirty-three underwent resection for pancreatic ductal adenocarcinoma and were included in our analysis, the remainder included resections for ampullary adenocarcinoma (n=20) or other malignancies (n=9). Patient, tumour and operative characteristics were analysed to assess predictors of survival following resection (Kaplan-Meier survival curves). RESULTS: Median survival following resection for ductal pancreatic adenocarcinoma was 54 months (ampullary adenocarcinomas achieved a median survival of 62 months) and thirty-day mortality was 2.7% (n=1). Survival was not associated with any demographic or intraoperative factors, such as blood loss, operative duration or anaesthetic technique. Survival curves were significantly worse when perineural or vascular invasion was evident histologically (p=0.023 and 0.0023 respectively). Patients with positive lymph nodes had a significantly shorter survival (p=0.0030) especially when lymph node status was expressed as a percentage of total lymph node yield. If more than 20% of retrieved lymph nodes were positive for tumour, this was a clear predictor of survival (p<0.0001). A positive resection margin was also associated with shortened survival (p=0.0291). CONCLUSION: Despite the advances made in the management of pancreatic cancer, tumour biology still dictates long-term survival. A highly selective surgical approach to the management of these patients results in good long-term survival.

Assessment of pancreatic malignancy with laparoscopy and intraoperative ultrasound.

BACKGROUND: Staging laparoscopy for pancreatic malignancy is controversial. This study aimed to assess the efficacy of laparoscopy with intraoperative ultrasound in the management of patients with pancreatic carcinoma. METHODS: The study involved patients undergoing laparoscopy and intraoperative ultrasound over a period of 42 months. The entry criteria specified radiologic (computed tomography) diagnosis of pancreatic carcinoma and no evidence of metastases. RESULTS: The study enrolled 100 patients (52 men and 48 women) ages 21 to 83 years (mean, 63 years). On the basis of imaging, 75 patients had lesions judged to be operable, and 25 patients had a pancreatic head lesion larger than 4 cm radiologically, considered to be unresectable, but with no evidence of metastatic disease. At laparoscopy, three patients had a normal examination, with no evidence of a pancreatic mass, and an additional seven patients had other pathology including one lymphoma, one ampullary tumor, two cases of chronic pancreatitis, and three sarcomas. Of the patients with radiologically inoperable disease, 16% had previously undetected metastases, but 24% were judged to be suitable for curative resection. Half of these patients underwent successful resection. Of the patients with radiologically operable disease, undetected liver or peritoneal metastases were found in 20% of the body or tail lesions and in 26% of the pancreatic head lesions. Of the pancreatic head tumors, 12% were found to be larger than 4 cm and therefore unsuitable for curative resection. Consequently, only 53% were confirmed to be suitable for resection. Of the patients explored with a view to curative resection, 42% actually underwent resection, with clearance of resection margins achieved in 77.8%. CONCLUSION: Of the patients thought to have a resectable tumor on the basis of good quality preoperative imaging, 44% had their management approach altered after laparoscopy and avoided an open procedure. Laparoscopy should therefore be used in the preoperative staging of pancreatic tumors.

Laparoscopic repair of direct inguinal hernia: a new technique that reduces the development of postoperative seroma.

BACKGROUND: Seroma are common early postoperative complications encountered in laparoscopic inguinal hernia repair. Previous anecdotal evidence from our surgical practice suggested a lower incidence of postoperative seroma formation with direct hernia repairs when the lax transversalis fascia (TF) is inverted by tacking to the pubic ramus. We undertook a study to investigate whether TF inversion in this way reduces the incidence of postoperative seroma. METHOD: A total of 216 patients undergoing transabdominal preperitoneal (TAPP) laparoscopic inguinal hernia repairs from August 2003 to December 2005 were included in this prospective non-randomised controlled study. Surgeon 1 would routinely invert the TF whereas surgeon 2 would not. At follow-up the presence of postoperative seroma and pain was recorded. RESULTS: Mann-Whitney U test demonstrated no significant difference in terms of age, sex and time to follow-up between the surgeons' patient groups (P > 0.05), and Chi-square test demonstrated significantly that inversion of the TF is associated with a lower incidence of postoperative seroma (P < 0.05). There was no significant difference in terms of postoperative pain at follow-up. CONCLUSION: Inversion of the TF is associated with a statistically lower incidence of postoperative seroma, without increasing postoperative pain despite the use of one or two additional tacks.

What's trending now? An analysis of trends in internet searches for labor epidurals.

BACKGROUND: The study aim was to investigate internet use for obtaining information about epidurals for labor and delivery. METHODS: Google Trends for US data was queried from 2004 to 2015 to find the most common searches and determine temporal trends. The Google Trends query used the term [epidural] and evaluated changes in search trends over time. Search comparisons were made for each year from 2004 to 2015, and three equal time epochs during the study period (2004-07, 2008-11, 2012-15) were compared. We also compared searches for epidurals with commonly searched birth-related terms. RESULTS: Internet searches are increasing; there were 726000 searches for [epidural] in 2015. Search terms with the most significant growth in the past 4years (2012-15) were "birth with epidural," "pain after epidural," "labor without epidural," "epidural birth video," and "epidural vs natural". Searches for epidural side effects, risks, and pain on insertion were among the most common and were increasing most rapidly. Searches related to epidurals were more common than searches related to "natural births", "home births", and "labor pain", but were less common than searches for "midwives" or "doulas". CONCLUSION: The findings provide an insight into internet use by those seeking information about labor analgesic options. Identifying the most common and rapidly increasing online search queries may guide physician-parturient interactions and online content creation, to address labor analgesic topics that most interest users.

Molecular prognostic markers in resectable colorectal liver metastases: a systematic review.

BACKGROUND: Determination of prognosis in patients with resectable colorectal liver metastases (CLM) is desirable in order to improve case selection for surgery and tailor adjuvant treatment according to individual recurrence risk. Conventional clinicopathological factors lack the sensitivity to accurately achieve this goal. Consideration of tumour biology and the identification of molecular prognostic markers may allow more accurate risk stratification. METHOD: This systematic review examines evidence from published manuscripts looking at molecular markers in resectable colorectal liver metastases and their correlation with disease recurrence and survival following hepatectomy. RESULTS: Studies have yielded promising results in the search for prognostic molecular markers of CLM. Molecular biomarkers from varied aspects of tumour biology have been examined and a number of these, including proliferation indices, telomerase, thymidylate synthase, microvessel density and thrombospondin-1 appear to have prognostic utility in this context. Validation of other markers, notably p53, has been limited by a failure of methodologies to account for their biological complexity. CONCLUSIONS: A biomarker-based approach may yield significant benefits through informed treatment of resectable metastatic colorectal malignancy. Standardised retrospective analyses are necessary to confirm preliminary findings and identify existing and novel markers for inclusion into prospective studies. Assessment and verification of multiple molecular markers in this manner may allow molecular profiling of metastases and tailoring of therapy according to the biological aggressiveness of individual tumours. The advent of genomic- and proteomic-based technologies will allow the simultaneous analysis of multiple molecular markers and the derivation of disease profiles associated with disease recurrence and poor survival.

The introduction of a nutrition clinical nurse specialist results in a reduction in the rate of catheter sepsis.

BACKGROUND: Catheter-related sepsis remains the major confounding factor in the long-term delivery of TPN. Previous studies have shown that the introduction of clinical nurse specialists (CNS) can lead to a reduction in sepsis from TPN catheters. This retrospective study aimed to determine the impact of a nutrition CNS on the rate of catheter-related sepsis. Furthermore, the cost of providing such a service was examined to see if it was offset from the savings obtained from reducing venous access infection. METHODS: Prior to the employment of a nutrition CNS, the total number of septic catheter complications were retrospectively collected over a 12-month period. Following appointment of the CNS, all patients requiring TPN were prospectively studied for signs of catheter-related sepsis and the data collected over a 4-year period. RESULTS: The overall sepsis rate (cumulative percentage) fell significantly in the 4-year period after the nutrition CNS was appointed, from 52% to 2.3%. The reduction in venous catheter access was accompanied by a decrease in cost related to wastage of TPN and insertion of new Hickman lines. CONCLUSION: The role of the CNS is primarily to improve the quality of care provided, but also to provide cost effectiveness. We have demonstrated that in addition to reducing infection rate of central venous catheters; the cost of employing a nutrition CNS is almost completely covered by the savings resulting from the reduction in wasted central venous catheters, TPN and operating time.

A coculture model of intrahepatic islet transplantation: activation of Kupffer cells by islets and acinar tissue.

Clinical and experimental studies of intrahepatic islet transplantation have allowed histological and systemic observations to be made, but the location of the transplanted islets makes it difficult to assess direct effects on the cells of the liver. An in vitro coculture model of Kupffer cells with islets or pancreatic acinar tissue is described, using porcine tissue and measuring the secretion of thromboxane B2, prostaglandin E2, 6-keto-prostaglandin F1alpha, and prostaglandin F2alpha as an indicator of Kupffer cell stimulation. The results have demonstrated activation of Kupffer cells in the presence of acinar or islet tissue, both when the cells were in direct contact and when separated by a membrane. This indicated that the stimulation was due to a soluble factor or factors, and was confirmed by the culture of Kupffer cells with acinar conditioned medium. The degree of stimulation was much greater with acinar tissue than with islets. In subsequent experiments, aprotinin, an enzyme activation inhibitor, was added to the cocultures in an attempt to reduce Kupffer cell activation. This had no effect, possibly due to the fact that the endogenous pancreatic enzymes may already be activated during digestion of the pancreas. Aprotinin alone caused an increase in secretion of eicosanoids from Kupffer cells. The high response to acinar tissue is of particular relevance to islet autotransplantation in which unpurified pancreatic digest is often transplanted. The clinical effectiveness of aprotinin in the light of these results is discussed. In conclusion, although unable to mimic the complex situation following intrahepatic islet transplantation, the coculture model described here allows the opportunity to assess the events relating to specific cell types, and will provide the scope to undertake more detailed studies on the mechanisms involved. The same model could be applied to the coculture of pancreatic tissue with hepatocytes to determine any effects on the normal function of hepatocytes.

Endoscopic-assisted intrathoracic oesophagogastrostomy without thoracotomy for tumours of the lower oesophagus and cardia.

AIMS: This study aimed to evaluate the efficacy of a novel technique enabling a trans-hiatal oesophagectomy with intrathoracic anastomosis under direct vision, without thoracotomy. METHODS: Trans-hiatal dissection of the oesophagus was performed using direct and laparoscopic visualization. The oesophagus was transected above the tumour with a linear endo-GIA-2 60 mum stapler. The stomach was transected and a gastric tube fashioned. The anvil of an appropriately sized CEEA circular stapler was modified enabling it to flatten. It was attached to a novel delivery system introduced under direct vision along a guidewire into the stapled oesophagus. The anvil was realigned to its original position in the distal oesophagus, docked with the body of the stapler and an intrathoracic anastomosis performed. RESULTS: Ten patients (female n=3, male n=7) aged from 39--77 years (mean age 65 years), ASA 2--3 with distal third tumours were treated. Duration of procedure ranged from 2--5 hours (mean 4 hours). One patient suffered a post-operative chest infection and an anastomotic leak treated successfully with a self-expanding metal stent. Hospital stay ranged from 6--28 days (mean 17 days). There was no mortality. CONCLUSION: This technique allows a safe intrathoracic anastomosis to be performed trans-hiatally under direct vision, avoiding the need for thoracotomy in patients with high comorbidity.

The feasibility of spleen-preserving pancreatectomy for end-stage chronic pancreatitis.

BACKGROUND: It is considered difficult to preserve the spleen at the time of distal or total pancreas resection for chronic pancreatitis (CP). The aim of this study was to assess the feasibility of preserving the spleen in patients requiring total or completion pancreatectomy for CP. METHODS: All patients having total or completion pancreatectomy for CP were evaluated postoperatively in terms of morbidity, mortality, and pain relief. To assess splenic vascularity, all patients underwent abdominal ultrasound and power doppler imaging to assess splenic perfusion and the patency of the remaining splenic vessels. RESULTS: Of 35 patients having total pancreatectomy, the spleen was preserved in 30 patients (19 women, 11 men; median age 40 years). The etiology of CP was mainly idiopathic (n = 14) or alcohol related (n = 12). All patients presented with chronic abdominal pain (median 5 years) requiring opiate-derived analgesia for pain relief. Fifteen patients (50%) had undergone previous therapeutic intervention for pain relief. The spleen was preserved with either an intact splenic artery and vein in 19 patients and or the short gastric vessels (n = 11). The mean duration of the procedure was 7 hours (range 5 to 11) and mean blood loss was 1,090 mL. The 30-day mortality was 3.8% (n = 1). Five patients had splenic complications (17%). These included splenectomy (n = 2), intrasplenic collection (n = 2), and a wedge splenic infarct (n = 1). Two of these complications were related to intrasplenic islet autotransplants. Follow-up with abdominal ultrasound and power doppler scanning showed no other abnormalities; blood flow was demonstrable in all patients with intact splenic arteries and vein (n = 19). The mean hospital stay was 25 days. Of the 24 patients who were beyond 6 months' follow-up, 82% (n = 20) have complete relief of pain, and 4 still require opiate analgesia. CONCLUSIONS: Spleen-preserving pancreatectomy is a feasible procedure for chronic pancreatitis, providing complete pain relief in 80% of patients. When the splenic artery and vein cannot be preserved, there is a minimal risk of splenic complications that may require further treatment; but for the majority of patients, splenectomy is avoided.

Incidental adult nesidioblastosis after distal pancreatectomy for endocrine microadenoma.

Persistent hyperinsulinaemic hypoglycaemia (nesidioblastosis) presenting with hypoglycaemia is extremely rare in adults. The features are suggestive of an insulinoma with a vague presentation and delayed diagnosis. We describe a report of adult nesidioblastosis in association with a pancreatic endocrine microadenoma.

A prospective controlled trial of the efficacy of isopropyl alcohol wipes before venesection in surgical patients.

It has previously been suggested that skin preparation before venesection with antiseptic agents is unnecessary. However thousands of doctors and medical students continue to use isopropyl alcohol (IPA) swabs for venesection, at an estimated cost of 10,000 P per annum in a 500 bed hospital. An audit of IPA swab use among junior doctors and medical students at our institution was undertaken; 76% of doctors and 100% of medical students routinely prepared the skin with alcohol before venesection and only one used the swabs correctly. A randomised single-blind controlled trial was conducted of IPA versus no IPA skin preparation before venesection. There were 194 patients in the study, 93 in the IPA group and 101 controls. There was no statistical difference with respect to complications at the venepuncture site between the two groups.

Experience of combined endoscopic percutaneous stenting with ultrasound guidance for drainage of pancreatic pseudocycts.

The therapeutic options for treatment of pancreatic pseudocysts are numerous. We report our experience of combined endoscopic and ultrasound guided percutaneous stenting for pancreatic pseudocysts. Data were prospectively collected for 20 consecutive patients. All patients had undergone a standard technique of combined endoscopic and ultrasound guided percutaneous placement of double J stents, between a pancreatic pseudocyst and the stomach. Patients age ranged between 25 and 84 years. Thirteen of the pseudocysts were due to acute pancreatitis and 7 were due to chronic pancreatitis. The duration of the combined procedure was mean 50 min (range 30-95 min). The length of hospital stay was mean 5 days (range 2-77 days. Only two patients suffered postoperative complications; one was re-admitted 2 weeks following stenting with acute cholecystitis, the other suffering a perforated duodenal ulcer 3 weeks after stenting. There were two failures early in the series, both due to stent migration, these stents were of a small size, (4.7 French). Following this the stent size was increased to at least 7 French, no further failures occurred. There was no operative mortality for the series. Follow-up ranged between 6 months and 5 years. We conclude that a combined percutaneous and endoscopic cyst-gastrostomy stent is a safe and effective treatment for patients with suitably placed pseudocysts.

The evolution of a vascular surgeon at a district general hospital: is sub-specialisation inevitable?

We report a 15-year retrospective audit to evaluate the change in arterial surgical commitment on general surgical case mix of a single surgeon with a vascular interest at a district general hospital. There was a 409% increase in the number of arterial procedures performed combined with a fall of 52% in the total number of operations over the study period. We conclude that, with such a rapidly growing arterial caseload, sub-specialisation to vascular surgery is inevitable.

Effect of fiber on cholesterol metabolism in the Coturnix quail.

This experiment involving 288 Coturnix quail was conducted to determine the effects of various fiber sources (alfalfa, wheat bran, dried brewer's grain, cellulose, and pectin) on serum, liver and egg yolk cholesterol, and egg production. The fiber sources were added at a rate to provide 6.25% fiber to a corn-soybean meal diet and fed for a 28-day experimental period. Serum, liver, and egg cholesterol levels were measured as pen composite samples at the end of the experimental period. No difference was exhibited in egg yolk cholesterol among any of the groups (P greater than .10). Liver and serum cholesterol levels were elevated in the birds fed the pectin and wheat brain diets as compared with that in birds fed the other fiber source; also, metabolizable energy intakes and eggs per hen day (EHD) were decreased for both groups. When data were adjusted for EHD by covariance analysis, the treatment differences no longer appeared (P greater than .05). These results indicate that 1) there is a basal quantity of cholesterol deposited in the egg on which fiber intake, energy consumed, or egg production have very little effect and that 2) there is an inverse relationship between serum and tissue cholesterol levels and the total quantity of cholesterol excreted via the egg.

Biological availability of selenodicysteine in chicks.

The biological availability of selenium (Se) in selenodicysteine (SDC) for chicks was evaluated using plasma glutathione peroxidase (SeGSHpx) activity and tissue Se levels as criteria. In each of two trials day-old Single Comb White Leghorn chicks were fed a basal diet low in Se but supplemented with vitamin E during Days 1 to 14. On Day 15 three replicate groups of eight chicks were assigned to each dietary treatment. Dietary treatments consisted of feeding the basal diet alone or supplemented with approximately 50, 100, or 150 ppb Se as either sodium selenite or SDC from Days 15 to 27. Pooled samples of blood, liver, and breast muscle were obtained from four chicks per replicate group on Day 27. Activity of SeGSHpx and the concentration of Se in plasma, whole blood, muscle, and liver were highly correlated (P less than .0001) with supplemental dietary Se. In Trial 1 no differences were observed between the slopes for each compound upon determining linear regression equations for SeGSHpx, plasma Se, whole blood Se, muscle Se, or liver Se versus supplemental dietary Se. In Trial 2 there were no differences between the slopes for each compound in equations for SeGSHpx, plasma Se, or whole blood Se versus supplemental dietary Se. The ratio of slopes (SDC/sodium selenite) was .82 for both muscle Se and liver Se versus dietary Se. Thus, data indicate that Se in SDC is highly available for chicks.