Prospective validation of an initial cholecystectomy strategy for patients at intermediate-risk of common bile duct stone.

BACKGROUND AND AIMS: Initial cholecystectomy for patients at intermediate risk of common bile duct (CBD) stones (including increased liver function tests but bilirubin <4 mg/dL and no cholangitis) showed shorter length of stay and fewer CBD investigations without increased morbidity compared with sequential CBD endoscopic assessment and subsequent cholecystectomy in a randomized controlled trial. The objectives were to prospectively validate these results in daily clinical practice and discuss current guidelines. METHODS: Initial cholecystectomy has become the standard management strategy at Geneva University Hospitals since July 2013 for patients at intermediate risk of CBD stones admitted with acute gallstone-related conditions. Between July 2013 and December 2014, length of stay, number of CBD investigations, and number of adverse events were recorded for these patients and compared with the data of the patients in the randomized controlled trial. RESULTS: Data for 161 consecutive newly assessed patients at intermediate risk of CBD stones confirmed shorter length of stay (7.6 vs 9.8 days; P < .001), fewer CBD investigations (0.8 vs 1.4 investigations per patient; P < .001), and similar adverse event rates (5.6% vs 14%, P = .14 including all adverse events; 3.1% vs 8%, P = .22 including only grade ≥III adverse events, defined by endoscopic/surgical reintervention or intensive care unit admission) compared with the previously reported group of patients who underwent preoperative CBD investigations. CONCLUSIONS: These data confirm that initial cholecystectomy results in a shorter length of stay without increased morbidity among patients at intermediate risk of CBD stones compared with sequential CBD assessment and subsequent cholecystectomy. This approach may change current guidelines.

Management of suspected common bile duct stones on cholangiogram during same-stay cholecystectomy for acute gallstone-related disease.

BACKGROUND: Recent data have suggested that upfront cholecystectomy should be performed even in the presence of moderately abnormal liver function tests (LFTs). As a consequence, more common bile duct (CBD) stones are discovered on intra-operative cholangiogram. We assessed the presentation and management of such patients to refine their management plan. METHODS: Adult patients (>16 years) with an acute gallstone-related disease who had undergone same-stay cholecystectomy from January 2013 to January 2015 were retrospectively assessed. We excluded patients with pre-operative endoscopic CBD exploration. RESULTS: Among the 612 patients with same-stay cholecystectomy, 399 patients were included in the study, and 213 were excluded because of a pre-operative CBD exploration. Fifty patients (12.5%) presented an image of CBD stone on the intra-operative cholangiogram. Such patients were younger (47 vs. 55 years, P = .01) and less likely to present with fever (1 vs. 11.7%, P = .04) or signs of cholecystitis on ultrasound (66 vs. 83.7%, P = .003). Admission LFTs were higher in patients with an image of a stone. Among the 50 patients with an image on cholangiogram, a stone was confirmed in 26 (52%). Most patients (n = 32) underwent post-operative assessment with endoscopic ultrasound (EUS). LFTs did not predict the presence of a confirmed stone. However, the absence of contrast passage into the duodenum was negatively associated with a confirmed stone (P = .08), and a filling defect was positively associated with one (P = .11). Most confirmed stones were successfully extracted by endoscopic retrograde cholangiopancreatogram (ERCP) (25/26, 96%), except in one patient who needed a per-cutaneous approach because of duodenal diverticuli. CONCLUSIONS: Same-stay cholecystectomy can (and should) be performed even in the presence of moderately abnormal liver function tests. The cholangiogram suspicion of a CBD stone is confirmed in only half of the patients (more often in the presence of a filling defect, and less often with the absence of contrast passage). All stones can be safely treated after surgery (most by ERCP).

Peri-implant Parameters of Dental Implants Inserted in Prefabricated Microvascular Fibular Flaps: A Retrospective Study.

PURPOSE: To assess the peri-implant and flap parameters of the prefabricated microvascular fibula flap and determine the dental implant survival rate. MATERIALS AND METHODS: This retrospective study investigated a cohort of subjects who received prefabricated microvascular fibula flaps at two highly specialized tumor reconstruction centers. The subjects had all suffered atrophy or a large segmental defect of the jaws due to tumor resection or injury. Two independent surgeons determined the dental implant survival rate and assessed the peri-implant parameters and flap parameters during clinical follow-up. RESULTS: In total, 41 subjects were treated with a prefabricated fibula flap between 1999 and 2012. Of these, 17 subjects (10 male, 7 female) with a total of 62 dental implants were examined. The other 24 subjects were unavailable for assessment and had to be excluded. Ten of the 62 dental implants (16.1%) had to be removed due to peri-implantitis before the follow-up assessment. Follow-up assessments were performed at intervals ranging from 2 to 12 years (mean: 7.2 years) after fibula flap transplantation. The dental implant survival rate was found to be 83.9%. A total of 208 dental surfaces were assessed. Overall, 96% of all surfaces had a pocket depth (PD) of ≤ 4 mm and 4% had a pocket depth of > 5 mm. An attachment level (AL) of 3 mm was measured in 48.5% of implants and ≥ 5 mm was measured in 15.9% of implants. Dental implants with a PD > 4 mm showed a significantly higher plaque index (PI) (75%; P = .0057), papillary bleeding index (PBI) (62.5%; P = .0094), and radiologic bone loss (P = .0014) compared to dental implants with a PD ≤ 4 mm. CONCLUSIONS: Reconstructive surgery using microvascular fibula flaps represents an alternative tool for oral rehabilitation in subjects suffering from a large segmental defect in the maxillary or mandibular bone compared to the conventional method. However, it appears that the different ossification processes that develop the fibula and the jawbones affect dental implant survival.

Peri-implant Parameters of Dental Implants Inserted in Prefabricated Microvascular Fibular Flaps: A Retrospective Study.

PURPOSE: To assess the peri-implant and flap parameters of the prefabricated microvascular fibula flap and determine the dental implant survival rate. MATERIALS AND METHODS: This retrospective study investigated a cohort of subjects who received prefabricated microvascular fibula flaps at two highly specialized tumor reconstruction centers. The subjects had all suffered atrophy or a large segmental defect of the jaws due to tumor resection or injury. Two independent surgeons determined the dental implant survival rate and assessed the peri-implant parameters and flap parameters during clinical follow-up. RESULTS: In total, 41 subjects were treated with a prefabricated fibula flap between 1999 and 2012. Of these, 17 subjects (10 male, 7 female) with a total of 62 dental implants were examined. The other 24 subjects were unavailable for assessment and had to be excluded. Ten of the 62 dental implants (16.1%) had to be removed due to peri-implantitis before the follow-up assessment. Follow-up assessments were performed at intervals ranging from 2 to 12 years (mean: 7.2 years) after fibula flap transplantation. The dental implant survival rate was found to be 83.9%. A total of 208 dental surfaces were assessed. Overall, 96% of all surfaces had a pocket depth (PD) of ≤ 4 mm and 4% had a pocket depth of > 5 mm. An attachment level (AL) of 3 mm was measured in 48.5% of implants and ≥ 5 mm was measured in 15.9% of implants. Dental implants with a PD > 4 mm showed a significantly higher plaque index (PI) (75%; P = .0057), papillary bleeding index (PBI) (62.5%; P = .0094), and radiologic bone loss (P = .0014) compared to dental implants with a PD ≤ 4 mm. CONCLUSIONS: Reconstructive surgery using microvascular fibula flaps represents an alternative tool for oral rehabilitation in subjects suffering from a large segmental defect in the maxillary or mandibular bone compared to the conventional method. However, it appears that the different ossification processes that develop the fibula and the jawbones affect dental implant survival.

Effects of Early Weaning Associated with Alimentary Stress on Emotional and Feeding Behavior of Female Adult Wistar Rats.

Maternal lactation proves crucial for mammals' nutrition during their early development, influencing the development of adult physiological mechanisms. Its premature termination has been associated with several disorders, but these have been primarily documented in males, when they are most prevalent in women. Therefore, we subjected adult female Wistar rats to Early Weaning through maternal separation at age 15 days to acute alimentary stress in the form of visual and olfactory exposition to a cafeteria diet sans consumption for 22 days. We measured standard diet intake and water intake daily and cafeteria diet intake every 7 days. Additionally, we evaluated anxiety using the elevated plus maze and measured body weight in similar intervals. Results showed less consumption of the cafeteria diet among Early Weaning rats on day 2 and more time spent in the maze's central area by the Early Weaning rats during the basal evaluation and in the maze's open arms by control rats on day 7 when compared to the same group's basal time. No other significant differences were found. These results show the importance of determining the impact that female steroidal gonadal hormones such as estradiol have upon feeding behavior and anxiety and determining to what degree these parameters are influenced by hormonal action.

Patients' related sexual outcomes in colorectal surgery.

Background: Patients undergoing colorectal surgery (CRS) have an increased risk of developing sexual disorders, attributed to different mechanisms. In this context, sexual function (SF) assessment of patients before and after surgery is essential: to identify risk factors for sexual disorders as well as to minimize their impact on overall quality of life (QoL), allowing them a satisfying relationship and sexual life. Material and methods: Patients over 18 years of age who underwent a CRS in the University Hospital of Geneva, Switzerland, between June 2014 and February 2016 were included. Our main objective was to compare and analyze the evolution of SF, QoL, and marital satisfaction (MS) before and after CRS. Specific and standardized tests were used. Results: A cohort of 72 patients with a median age of 58.73 was analyzed. The majority of CRS was elective (91.5%). A percentage of 52.8% of patients underwent surgery for oncological reasons. There was no statistical difference in SF, sexual QoL, and MS before and after elective or emergency CRS for men. Interestingly, a significant decrease in women's SF (FSFI) as well as their satisfaction within their couple (Locke-Wallace) until 12 months after surgery was found (p = 0.021). However, they showed a steady SF (GRISS) within their couple until 12 months after surgery. Conclusion: Regarding knowledge about difficulties to talk about this intimate topic and gender differences, this general overview raises the question of the necessity to introduce in a long-course follow-up different methods of sexual health assessment with specific stakeholders.

Management of malignant pleural effusion and ascites by a triple access multi perforated large diameter catheter port system.

BACKGROUND: Pleural or peritoneal effusions (ascites) are frequent in terminal stage malignancies. Medical management may be hazardous. METHODS: A 60-year-old man with metastatic malignant melanoma presented refractory ascites as well as bilateral pleural effusions. After failure of the medical treatment, bilateral pleural aspiration and paracentesis became necessary two to three times a week. A multi perforated 15F silicone catheter connected with a subcutaneous port was implanted in peritoneal and both pleural cavities surgically under general anesthesia. Leakage around the catheter is prevented by subcutaneous tunneling. Surgical technique is described and illustrated in a video. RESULTS: Implanted systems were immediately operational. Follow up period was 41 days. Each port was accessed 10 times and a total of 65'200 ml of fluid was drained. By the end of the forth week, pleural effusions diminished, systems were controlled for permeability and chest x-rays confirmed absence of effusion. CONCLUSION: Implanted port systems for refractory ascites and pleural effusions avoid morbidity and the patient's anxiety related to repeated puncture-aspiration. Large catheter diameter allows an easy and fast drainage of large volumes. Compared to chronic indwelling catheters, subcutaneous location of port system allows an entire integration, giving the patient a total liberty in daily life between two sessions of drainage. Drainage can be performed in an outpatient basis as an ambulatory procedure. This patient-friendly technique may be a treatment option in case of failure of other techniques.

Feasibility, benefit and risk of systematic intraoperative cholangiogram in patients undergoing emergency cholecystectomy.

BACKGROUND: The role of intraoperative cholangiogram (IOC) during cholecystectomy is debated. The aim of the present study was to evaluate the feasibility, benefit and risk of performing systematic IOC in patients undergoing cholecystectomy for acute gallstone-related disease. METHODS: Between July 2013 and January 2015, all patients admitted for an acute gallstone-related condition and undergoing same-hospital-stay cholecystectomy were prospectively followed. IOC was systematically attempted and predictors of IOC failure were analyzed. RESULTS: Among the 581 enrolled patients, IOC was deliberately not performed in 3 cases. IOC was successful in 509/578 patients (88.1%). The main predictors of IOC failure were age, body mass index, male gender and associated acute cholecystitis. Thirty-two patients with suspected common bile duct stone on IOC underwent 38 unnecessary negative postoperative common bile duct investigations (32/509, 6.3%). There was one IOC-related adverse outcome (mild pancreatitis, 1/578, 0.2%). CONCLUSIONS: IOC can be successfully and safely performed in the majority of patients undergoing cholecystectomy for acute gallstone-related disease. Although its positive predictive value is suboptimal and results in a number of unnecessary postoperative common bile duct investigations, IOC accurately rules out common bile duct stones in patients with acute gallstone-related conditions.

Omental patch reinforced with polypropylene mesh and split-thickness skin grafting: A new procedure to close the "open abdomen".

INTRODUCTION: The "open abdomen" expression widely used to define a full-thickness defect of the abdominal wall intentionally made in some situations like abdominal compartment syndrome, has been replaced by a newest one called "laparostomy". The definitive closure of an open abdomen with a giant full abdominal thickness defect remains a problem. CASE REPORT: We present a 67-year old male with a descompressive laparostomy treated with a greater omentum flap sutured hermetically with interrupted stitches at the edges of the muscle wall, reinforced with large mesh of polypropylene (PP) placed on-lay and sutured to the fascia by two concentric running sutures of polypropylene. A vacuum-assisted closure device was placed on the second postoperative day and it was kept during three weeks. By then the PP mesh was completely integrated so skin grafts were applied to the surface of the granulation tissue. An incisional hernia was easily repaired at three years of follow-up. Eight months after the last surgery the patient is satisfied with the result achieved. DISCUSSION: The great omentum has immunological and angiogenic properties that allow a rapid integration of the polypropylene mesh, even in septic environments, facilitating the engraftment of split-thickness skin graft. The reactive fibrosis caused by the PP mesh replaces the fat tissue but the inner surface is preserved, thereby avoiding subsequent adhesion and facilitates surgical access to the abdominal cavity if necessary in the future. CONCLUSION: The structure achieved is a strong structure, capable of visceral isolation that can be useful to close some OA.

Promoción de la salud: la calidad de vida en las prácticas de enfermería / Health promotion: the quality of life in nursing practices

El objetivo fue reflexionar sobre la calidad de vida (CV) ofrecida en las prácticas de Enfermería con miras a la Promoción de la Salud, discutida desde la I Conferencia Internacional sobre Atención Primaria de Salud en Alma-Ata (1978), reforzada más tarde en las Conferencias sobre Promoción de la Salud y que tiene relación directa con la calidad de vida. Esta es entendida como la percepción de la persona sobre su vida, en el contexto cultural y social, asociada con los deseos, objetivos, expectativas e influenciada por el estado de salud. El enfermero desempeña papel importante en todos los niveles de atención, siendo profesional estratégico para proporcionar cambios en el estilo de vida de las personas que promueven la salud, por lo tanto, la calidad de vida, a través de su cuidado y del "empoderamiento" de la persona y su familia. Algunas experiencias confirman la intervención de enfermería con los pacientes con ciertas afecciones crónicas, individuales o colectivas, que promueven la salud. Es necesario sensibilizar cada vez más el personal de salud y de Enfermería, en particular, a promover la salud en el contexto del Sistema Único de Salud (SUS), para colaborar a la mejora de la calidad de vida de la sociedad (AU)

This study aimed to reflect on the quality of life provided in nursing practices seeking Health Promotion, a discussion that happens since the International Conference on Primary Health Care in Alma-Ata (1978), later reinforced in the Conferences on Health Promotion and that is directly related to the quality of life. This is understood as the perception that someone has about their life in the cultural and social context, associated with desires, goals and expectations, and influenced by health conditions. The nurse plays an important role in all levels of care, being an essential professional to promote changes in the lifestyle of the people that promote health and consequently in the quality of life, through their care and "empowerment" of the person and their family. Some experiments confirm the health promotion of nursing practices with patients with certain chronic conditions, individual or collective. We conclude that it is necessary to increasingly sensitize the health and nursing staff, especially for health promotion in the context of SUS, who collaborate to improve the quality of life of society (AU)