B-type natriuretic peptide levels may be elevated in the critically injured trauma patient without congestive heart failure.

BACKGROUND: Rapid diagnosis of congestive heart failure (CHF) is essential to treatment. B-type natriuretic peptide (BNP) is a neurohormone secreted by the heart in response to fluid overload and has been shown to be elevated in medical patients with left ventricular dysfunction. However, BNP has not been evaluated in the critically ill patient with trauma. METHODS: Trauma patients of at least 18 years of age with an expected intensive care unit stay of at least 24 hours were studied. Patients had BNP measurements at admission and at 24 hours and 48 hours. Echocardiography was performed within 48 hours of admission. CHF was determined by echocardiographic findings of systolic or diastolic dysfunction. Elevated BNP levels were defined as those greater than 100 pg/mL. A Fisher's exact test was performed to determine whether a relationship between BNP levels and echocardiographic findings existed. Linear correlation was used to determine whether BNP correlated with echocardiographic findings and initial Glasgow Coma Scores. RESULTS: Fifty patients were included in the analysis. There was no relationship between elevated BNP levels and echocardiographic evidence of CHF (p = 0.149). There was no threshold value above which CHF was present. There were 28 patients with head injuries, and no relationship between BNP levels and CHF could be found (p = 0.432) in this group. CONCLUSION: Our data show no association between BNP and CHF in the critically ill patient with trauma. BNP levels may be elevated in patients with head injuries without echocardiographic evidence of CHF.

Retrievable inferior vena cava filters may be safely applied in gastric bypass surgery.

INTRODUCTION: Pulmonary embolus (PE) is a potentially devastating and fatal postoperative complication in morbidly obese patients. This study was undertaken to review the safety and efficacy of retrievable prophylactic inferior vena cava (IVC) filters in high-risk morbidly obese patients undergoing gastric bypass. METHODS: Patients who underwent gastric bypass surgery and preoperative insertion of retrievable IVC filters had their records reviewed. Indications for IVC filter insertion were: history of deep venous thrombosis (DVT) or PE, long-standing sleep apnea, venous stasis disease, and/or weight > 400 pounds. RESULTS: 24 patients underwent IVC filter placement before gastric bypass surgery. There were 10 women and 14 men with an average age of 50 +/- 6.3 years (range 39 to 59) and average body mass index (BMI) of 57 +/- 7.5 kg/m(2) (range 49 to 74). BMI greater then 50 kg/m(2) was present in 21 of 24 patients (88%). All patients had successful IVC filter placement. IVC filter retrieval postoperatively was performed in 20 of 24 patients (83%) with three left for clinical reasons and one (4%) left due to technical inability to retrieve. There was one complication directly attributable to IVC filter retrieval. There were no deaths. Five patients (21%) developed DVT or PE postoperatively. Follow-up was 16 +/- 7.6 months (range 8 to 33). CONCLUSIONS: Prophylactic IVC filter placement and retrieval can be safely undertaken in high-risk gastric bypass patients. We recommend preoperative IVC filter placement in selected patients.

Ruptured abdominal aortic aneurysm: does trauma center designation affect outcome?

Ruptured abdominal aortic aneurysm (RAAA) continues to be a major cause of mortality in the United States. Rapid diagnosis and uncomplicated surgical repair remain paramount to improving survival in this population. We proposed that the addition of an organized trauma service and subsequent improved management of critically ill patients who present with RAAA would positively impact overall mortality. A retrospective analysis was performed on all patients treated for RAAA at Santa Barbara Cottage Hospital for the years 1985-2004. Patients treated before level II trauma center designation (1985-1999) were compared to those treated after the trauma center was instituted. A total of 76 patients were included in this analysis. The two groups were similar with regard to demographics. However, significant decreases in transport time from the emergency department to the operating room and overall 30-day mortality were seen in patients after the trauma center designation. This designation also led to an increase in the number of cases performed per year, centralizing the treatment for these critically ill patients. Institution of a well-prepared and organized service, such as trauma, improved the outcome for patients treated with RAAA, with a particular benefit in the unstable patient.

Is there a benefit to preoperative weight loss in gastric bypass patients? A prospective randomized trial.

BACKGROUND: Roux-en-Y gastric bypass surgery is the leading surgical treatment of morbid obesity in the United States. The role of preoperative weight loss in gastric bypass surgery remains controversial. We performed a prospective randomized trial to determine whether preoperative weight loss results in better outcomes after laparoscopic gastric bypass. METHODS: A total of 100 patients undergoing laparoscopic gastric bypass surgery from May 2004 to October 2005 were randomized preoperatively to either a weight loss group with a 10% weight loss requirement or a group that had no weight loss requirements. The patients were followed prospectively. The variables analyzed included perioperative complications, operative time, postoperative weight loss, and resolution of co-morbidities. RESULTS: Data were available for 26 patients in the weight loss group and 35 in the nonweight loss group. The 2 groups had similar preoperative characteristics, conversion and complication rates, and resolution of co-morbidities. The initial body mass index was 48.7 kg/m(2) and 49.3 kg/m(2) for the weight loss group and nonweight loss group, respectively (P = NS). The preoperative body mass index was 44.5 kg/m(2) and 50.7 kg/m(2) for the weight loss group and nonweight loss group, respectively (P = 0.0027). The operative time was 220.2 and 257.6 minutes for the 2 groups (P = 0.0084). The percentage of excess weight loss at 3 and 6 months for the weight loss group and nonweight loss group was 44.1% and 33.1% (P = 0.0267) and 53.9% and 50.9% (P = NS), respectively. The interval to surgery from the initial consultation was 5.4 months and 5.2 months for the 2 groups (P = NS). CONCLUSIONS: Preoperative weight loss before laparoscopic Roux-en-Y gastric bypass was associated with a decrease in the operating room time and an improved percentage of excess weight loss in the short term. Preoperative weight loss, however, did not affect the major complication or conversion rates, and its long-term effects were not apparent through this study. Also, preoperative weight loss did not have any bearing on the resolution of co-morbidities.

Postural ergonomics during robotic and laparoscopic gastric bypass surgery: a pilot project.

We hypothesized that a laparoscopic technique for Roux-en-Y gastric bypass surgery is associated with more musculoskeletal discomfort and ergonomic strain than a robotic technique. This pilot project studied one surgeon while he performed four laparoscopic and four robotic (da Vinci system) Roux-en-Y gastric bypass procedures. We measured musculoskeletal discomfort with body part discomfort score (BPD) and ergonomic positioning with the rapid upper-limb assessment tool (RULA). At the end of the case, the robotic cases were associated with more discomfort in the neck (median BPD scores 2.5 versus 1.0, P = 0.028), while the laparoscopic cases were associated with more discomfort in the upper back (median BPD scores 2.0 versus 1.0, P = 0.028). Both the right and left shoulders demonstrated more discomfort with the laparoscopic group (median BPD scores 3.0 versus 1.5, P = 0.057). The RULA analysis demonstrated that the upper arm (1.0 versus 2.25), lower arm (1.125 versus 2.125), wrist (2.5 versus 3.5) and wrist twist (1.25 versus 2) were held in less ergonomically correct positioning (higher score) in the laparoscopic group compared to the robotic group (P = 0.029). In contrast, the trunk (1.5 versus 1.0) had a worse RULA score in the robotic group compared to the laparoscopic cases. These pilot data suggest that robotic Roux-en-Y gastric bypass surgery may result in less musculoskeletal stress to the upper extremities than standard laparoscopic technique. In contrast, robotic surgery seems to offer both postural advantages and disadvantages for the neck and back region. More-detailed studies are needed to fully assess the potential postural advantages of robotic surgical techniques over standard laparoscopy.

Attitude of prospective surgical residents regarding surgery for morbid obesity.

BACKGROUND: Obesity and associated co-morbidities have become an epidemic in the United States. As surgery for obesity becomes more common, surgical training programs need to address this growing demand. We conducted this study to assess prospective surgery trainees' attitudes and knowledge regarding surgery for morbid obesity. METHODS: An anonymous and voluntary questionnaire was given to prospective surgical residency applicants to complete during their interview. The questionnaire included basic demographic information and addressed the applicants' attitudes and basic knowledge about surgery for obesity. RESULTS: 57 applicants to the surgical residency program completed the survey. Demographic information included: 51% male, 36% from the Northeast, 32% with obese family members, and 93% applying for a categorical surgery position. 81% of applicants had been exposed to bariatric surgery. Although 70% of applicants would perform bariatric surgery as part of their practice, only 44% would make this their career. Reasons for reluctance to treat bariatric surgery patients included: more complications (46%), non-compliant patients (33%), and technically demanding surgery (18%). 89% responded that they would recommend bariatric surgery to a family member, but only 77% would consider it for themselves. Overall correct answers regarding bariatric surgery knowledge were 74%. CONCLUSIONS: Attitudes and knowledge about surgery for morbid obesity were generally positive in prospective surgical trainees. Medical school curriculum and surgical training programs should continue to expose trainees to information from this ever-growing field.

The use of acellular dermal matrix for contaminated abdominal wall defects: wound status predicts success.

BACKGROUND: Contaminated abdominal wall fascial defects present a challenging problem. The use of human acellular dermal matrix (AlloDerm; LifeCell Corp., Branchburg, NJ) provides a novel method of primary closure of abdominal wall defects in this setting. The aim of the current study was to determine what factors predicted fascial wall failure as determined by the presence of hernia on follow-up exam after AlloDerm placement. METHODS: All patients who underwent surgery for contaminated abdominal wall fascial defects with placement of AlloDerm from June 2003 to September 2005 at a tertiary care Veterans Affairs hospital were included in the analysis. Patients were followed until hernia recurrence or last clinic visit. RESULTS: Eighteen patients had AlloDerm placed for contaminated fascial defects and all were included in the analysis. Primary wound closure was performed on 12/18 (67%) patients, with 6/18 (33%) patients initially left with open wounds. Patients with open wounds were treated with wound vacuum-assisted closure (VAC) devices (4/6) or saline dressings (2/6). Overall ventral hernia recurrence rate was 50% (9/18) with an average follow up of 9.1 months. Patients who had primary wound closure at the completion of the operation had a 33% (4/12) recurrence rate. Patients who did not have primary wound closure had an 83.3% (5/6) recurrence rate. The significant difference shows (P = .03) that open wound status predicts recurrence. The average size of AlloDerm sheets used was 164.0 cm2 in the closed group and 146.2 cm2 in the primary open wound group (P = .64). Average cost per patient was 4680 dollars for AlloDerm. CONCLUSION: These data suggest that an open wound in the postoperative period after AlloDerm placement for treatment of contaminated fascial defects is associated with a high probability of hernia recurrence. Our data do not support the use of this expensive material unless there is a good chance of having a closed wound.

A prospective study of nurse and patient education on compliance with sequential compression devices.

Sequential compression devices (SCD) have become the most common form of prophylaxis against the formation of deep venous thrombosis (DVT) among surgical patients. However, compliance with SCD has traditionally been poor. The aim of this study was to assess the affect of patient and nurse education by surgeons on SCD compliance. This was a prospective study involving a single teaching hospital. Compliance was checked twice daily. The main outcomes were compliance rates with SCD use before and after nurse and patient education. Nurses were not aware of the study. Surgical floors had a history of resident and attending interactions regarding SCD, whereas nonsurgical floors did not. A handout that emphasized SCD importance was also given to patients on surgical units. Before education, surgical units had a compliance rate of 61.5 per cent, whereas nonsurgical units had a 48 per cent compliance rate. This difference was significant (P = 0.014). After nursing and patient education on the busiest surgical floor, compliance rates on the surgical ward increased to 65 per cent, a difference that was not of statistical significance (P = 0.515). A nursing unit's daily experience is the most important factor in their compliance rates with SCD use. Focused nursing lectures and patient education may have incremental value.

Concurrent gastric bypass and repair of anterior abdominal wall hernias.

BACKGROUND: Many patients seeking surgical treatment for morbid obesity present with anterior abdominal wall hernias. Although principles of hernia repair involve a tension-free repair with the use of prosthetic mesh, there is concern about the use of mesh in gastric bypass surgery due to potential contamination with the contents of the gastrointestinal tract and resultant mesh infection. We report our series of patients undergoing Roux-en-Y gastric bypass (RYGBP) and simultaneous anterior abdominal wall hernia repair. METHODS: All patients who underwent simultaneous RYGBP surgery and anterior abdominal wall hernia repair were reviewed. RESULTS: 12 patients underwent concurrent RYGBP and anterior wall hernia repair. There were 5 women and 7 men with average age 54.9 +/- 8.5 years (range 35 to 64) and average body mass index (BMI) 50.4 +/- 10.3 kg/m(2) (range 38 to 70). Two open and 10 laparoscopic RYGBP operations were performed. Nine patients (75%) underwent incisional hernia repairs and 3 patients (25%) underwent umbilical hernia repair concurrent with gastric bypass. Average size of defect was 14.7 +/- 13.4 cm(2). One patient had primary repair and 11 patients had prosthetic mesh repair: polypropylene in 3 patients (25%) and polyester in 8 patients (67%). With a 14.1 +/- 9.3 month follow-up, there have been no mesh infections and 2 recurrences, one in the patient who underwent primary repair and one in a patient repaired with polyester mesh but with two previous failed incisional hernia repairs. CONCLUSION: Concurrent RYGBP and repair of anterior abdominal wall hernias is safe and feasible. In order to optimize success, tension-free principles of hernia repair with the use of prosthetic mesh should be followed since no mesh infections occurred in our series.

Intra-operative fluid volume influences postoperative nausea and vomiting after laparoscopic gastric bypass surgery.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (RYGBP) is a commonly performed operation for morbid obesity. A significant number of patients experience postoperative nausea and vomiting (PONV) following this procedure. The aim of this study was to determine the effect, if any, of intra-operative fluid replacement on PONV. METHODS: Patients who underwent laparoscopic (RYGBP) for morbid obesity during a 12-month period were included in this retrospective analysis. Demographic data including age, gender, and body mass index (BMI) were collected. Perioperative data also included total volume of intra-operative fluids administered, rate of administration, urine output, length of surgery, and incidence of PONV as determined by nursing or anesthesia records in the postanesthesia care unit (PACU). Data were analyzed by t-test. RESULTS: The table below depicts demographic and perioperative data, comparing patients who experienced PONV (n=125) in the PACU with those who did not (n=55). Values are mean +/- standard deviation. CONCLUSIONS: PONV is a common complication after laparoscopic RYGB. Patient who did not experience PONV received a larger volume of intravenous fluid at a faster rate than similar patients who complained of PONV.

The use of vacuum-assisted closure therapy for the treatment of a large infected facial wound.

Chronic wounds in difficult locations pose constant challenges to health care providers. Negative-pressure wound therapy is a relatively new treatment to promote wound healing. Laboratory and clinical studies have shown that the vacuum-assisted closure (VAC) therapy increases wound blood flow, granulation tissue formation, and decreases accumulation of fluid and bacteria. VAC therapy has been shown to hasten wound closure and formation of granulation tissue in a variety of settings. Accepted indications for VAC therapy include the infected sternum, open abdomen, chronic, nonhealing extremity wounds and decubitus ulcers. We report the first case of VAC therapy successfully used on a large infected wound to the face to promote healing.

Gum chewing reduces ileus after elective open sigmoid colectomy.

HYPOTHESIS: Gum chewing after elective open colon resection may stimulate bowel motility and decrease duration of postoperative ileus. DESIGN AND SETTING: Prospective, randomized study in a community-based teaching hospital. PATIENTS: Thirty-four patients undergoing elective open sigmoid resections for recurrent diverticulitis or cancer. MAIN OUTCOME MEASURES: First feelings of hunger, time to first flatus, time to first bowel movement, length of hospital stay, and complications. RESULTS: A total of 34 patients were randomized into 2 groups: a gum-chewing group (n = 17) or a control group (n = 17). The patients in the gum-chewing group chewed sugarless gum 3 times daily for 1 hour each time until discharge. Patient demographics, intraoperative, and postoperative care were equivalent between the 2 groups. All gum-chewing patients tolerated the gum. The first passage of flatus occurred on postoperative hour 65.4 in the gum-chewing group and on hour 80.2 in the control group (P = .05). The first bowel movement occurred on postoperative hour 63.2 in the gum-chewing group and on hour 89.4 in the control group (P = .04). The first feelings of hunger were felt on postoperative hour 63.5 in the gum-chewing group and on hour 72.8 in the control group (P = .27). There were no major complications in either group. The total length of hospital stay was shorter in the gum-chewing group (day 4.3) than in the control group (day 6.8), (P = .01). CONCLUSIONS: Gum chewing speeds recovery after elective open sigmoid resection by stimulating bowel motility. Gum chewing is an inexpensive and helpful adjunct to postoperative care after colectomy.

Magnetic resonance imaging is not needed to clear cervical spines in blunt trauma patients with normal computed tomographic results and no motor deficits.

HYPOTHESIS: Trauma patients with normal motor examination results and normal cervical spine helical computed tomographic (CT) scans with sagittal reconstructions do not have significant cervical spine injury. DESIGN: Prospectively collected registry data. SETTING: Level II community-based trauma center. PATIENTS: All patients admitted to the trauma service from January 1, 1999, to December 31, 2003. MAIN OUTCOME MEASURES: Injury detected by CT and/or magnetic resonance imaging (MRI) of the cervical spine. Neurologic examination and need for surgery were secondary outcomes. RESULTS: During the study period, 2854 trauma patients were admitted, of whom 91.2% had blunt trauma. Of these patients, 56.2% had a closed head injury. One hundred patients had cervical spine and/or spinal cord injuries. Eighty-five patients had a cervical spine injury diagnosed by CT. Fifteen patients had admission neurologic deficits not seen on CT, and 7 of these patients had non-bony abnormalities on MRI. Ninety-three patients had a normal admission motor examination result, a CT result negative for trauma, and persistent cervical spine pain, and were examined with MRI. All MRI examination results were negative for clinically significant injury. Seventeen patients had MRIs that showed degenerative disc disease, and 6 had spinal canal stenosis secondary to ossification. Twelve comatose patients (Glasgow Coma Scale score, <9), moving all 4 extremities on arrival, with normal CT results of the cervical spine, were examined with MRI. All of these MRI examination results were negative for injury. None of the patients experienced neurologic deterioration. No patient required operative management of spinal injury. CONCLUSION: Blunt trauma patients with normal motor examination results and normal CT results of the cervical spine do not require further radiologic examination before clearing the cervical spine.

Is repeated head computed tomography necessary for traumatic intracranial hemorrhage?

This study was performed to determine the need for repeat head computed tomography (CT) in patients with blunt traumatic intracranial hemorrhage (ICH) who were initially treated nonoperatively and to determine which factors predicted observation failure or success. A total of 1,462 patients were admitted to our level II trauma center for treatment of head injury. Seventeen per cent (255/1,462) were diagnosed with ICH on initial head CT. Craniotomy was initially performed in 15.7 per cent (40/255) of patients with ICH. Two hundred sixteen patients with ICH were initially observed. Ninety-seven per cent (179/184) of observed patients with ICH and repeat head CT never underwent a craniotomy, 2.7 per cent (5/184) of patients with ICH initially observed underwent craniotomy after repeat head CT, and four patients (80%) had deteriorating neurologic status. Multivariate analysis revealed the following significant admission risk factors were associated with a need for repeat head CT indicating the need for craniotomy: treatment with anticoagulation and/or antiplatelet medications, elevated prothrombin time (PT), and age greater than 70 years. In patients with blunt traumatic intracranial hemorrhage initially observed, there is little utility of repeated head CT in the absence of deteriorating neurologic status. The only admission risk factors for a repeat CT indicating the need for craniotomy were advanced age and coagulopathy.

Preoperative oral rofecoxib and postoperative pain in patients after laparoscopic cholecystectomy: a prospective, randomized, double-blinded, placebo-controlled trial.

Cyclooxygenase-2 (COX-2) inhibitors are a class of drugs that may avoid some of the side effects of narcotics and nonsteroidal anti-inflammatory drugs (NSAIDs). We performed a randomized, double-blinded, placebo-controlled trial giving a single oral dose of the COX-2 inhibitor rofecoxib 25 mg or placebo preoperatively to determine the impact upon postoperative pain, complications, narcotic use, and hospital stay after laparoscopic cholecystectomy. Investigators and patients were blinded. Pain was measured on a 10-point visual analogue scale. Eighty patients were randomized: 40 to the rofecoxib group and 40 to the placebo group. The amount of pain between the two groups postoperatively was equivalent. Pain was recorded at 1 hour, 4.03 +/- 1.93 in the rofecoxib group versus 4.38 +/- 1.34 in the placebo group (P = 0.36); at 6 hours, 3.00 +/- 1.12 in the rofecoxib group versus 2.78 +/- 0.78 in the placebo group (P = 0.42); and at 24 hours, 1.64 +/- 0.67 in the rofecoxib group versus 2.68 +/- 1.90 in the placebo group (P = 0.17). The amount of pain medication received and lengths of hospital stay was not significantly different between the two groups. Our data demonstrate no significant benefit of preoperative oral rofecoxib in patients undergoing laparoscopic cholecystectomy.

Treatment of bleeding in severe hemorrhagic pancreatitis with recombinant factor VIIa.

Recombinant factor VIIa (rFVIIa) has been used to treat bleeding complications in patients with hemophilia. It acts at the site of vessel injury, forming a complex with tissue factor to activate the clotting cascade. Recent reports have shown rFVIIa may be a useful hemostatic agent in patients after obstetrical, urologic, trauma, or transplant procedures. We report the first documented case of bleeding from hemorrhage pancreatitis treated with rFVIIa.