Insufflation in minimally invasive surgery: Is there any advantage in staying low?

AIM: Minimally invasive repair of esophageal atresia with tracheoesophageal fistula (EA/TEF) and congenital diaphragmatic hernia (CDH) is feasible and confers benefits compared to thoracotomy or laparotomy. However, carbon dioxide (CO2) insufflation can lead to hypercapnia and acidosis. We sought to determine the effect of lower insufflation pressures on patients' surrogate markers for CO2 absorption - arterial partial pressure of CO2 (PaCO2), end tidal CO2 (EtCO2) and pH. METHODS: Single center retrospective review, including neonates without major cardiac anomaly. Selected patients formed 2 groups: Historical pressure (HP) group and low pressure (LP) group. We reported on the patients' preoperative characteristics that potentially confound the degree of CO2 absorption or elimination. Outcome measures were perioperative PaCO2, EtCO2, arterial pH and anesthetic time. RESULTS: 30 patients underwent minimally invasive surgery for CDH and 24 patients for EA/TEF with similar distribution within the HP and LP group. For CDH patients as well as for EA/TEF patients, there were no significant differences in their preoperative characteristics or surgery duration comparing HP and LP groups. With a decrease in insufflation pressure in CDH patients, there were a significant decrease (p = 0.002) in peak PaCO2 and an improvement in nadir pH (p = 0.01). For the EA/TEF patients, the decrease in insufflation pressure was associated with a significant decrease (p = 0.03) in peak EtCO2. Considering all 54 patients, we found EtCO2 to be highly significantly inversely correlated with pH and positively correlated with intraoperative PaCO2 (p < 0.001). Baseline Hb was inversely correlated with mean EtCO2 (p < 0.001). CONCLUSION: With lower insufflation pressures, CDH patients had significantly improved hypercapnia and acidosis, while EA/TEF patients had significantly reduced EtCO2. EtCO2 was correlated with acidosis and hypercapnia. TYPE OF STUDY: Retrospective case control study. LEVEL OF EVIDENCE: Level III.

Thoracoscopic aortopexy for symptomatic tracheobronchomalacia.

AIM: Symptomatic tracheobronchomalacia can be fatal. Successful treatment includes aortopexy. We report outcomes of the thoracoscopic approach in a single centre. METHODS: All patients undergoing thoracoscopic aortopexies from 2009 to 2018 were retrospectively reviewed. Data was reported as median (interquartile range). Risk factors for subsequent tracheostomy were analyzed with logistics regression model, p < 0.05 as significant. RESULTS: Twenty-one patients with mid to distal tracheomalacia (n = 17) and bronchial involvement (n = 4) were determined on bronchoscopy, tracheobronchogram, or CT thorax. Preoperative patient demographics and comorbidities, e.g., gastro-oesophageal reflux disease, prematurity, and cardiac anomalies were recorded. Indications for thoracoscopic aortopexy were apparent life-threatening event(s) (n = 14), recurrent chest infections (n = 5), and failure to wean invasive ventilation (n = 2). Thoracoscopic aortopexies (n = 20) with conversion to open (n = 1) were performed. Intraoperative bleeding (n = 2) occurred, and chest tube (n = 1) was inserted for monitoring. Intraoperative bronchoscopy (n = 17) confirmed improvement of tracheomalacia. Anesthetic time was 140 (90-160) minutes. Postoperatively, 2 patients had dehiscence of the aorta from the sternum. They underwent redo open aortopexy with posterior tracheopexy, and 1 required subsequent tracheostomy. Another 2 patients required tracheostomies. Potential risk factors for subsequent tracheostomy were investigated, and only the association of tracheobronchomalacia was close to significance (OR 16 (95% CI 0.95-267.03), p = 0.05). Follow up duration was 365 (72-854) days. Symptoms resolution occurred in n = 17 (81%) of patients. CONCLUSION: Different modalities were used to delineate the site of tracheobronchomalacia and its etiology. Tracheomalacia with bronchial involvement may be a risk factor for subsequent tracheostomy. LEVEL OF EVIDENCE: Level 3 (Case Series).

What Happens after Kasai for Biliary Atresia? A European Multicenter Survey.

AIM: Biliary atresia (BA) remains a rare disease in Europe with an estimated incidence of 1 in 15-20,000 livebirths. While the Kasai portoenterostomy (KPE) is regarded as the standard operation for BA, there is no consensus on optimum adjuvant therapy. We sought to determine the variation in therapy and opinion in centers known to have an interest in pediatric hepatobiliary surgery across Europe. METHODS: A survey of current pre- and postoperative practice was circulated to surgeons and centers known to have an interest in BA. Data are quoted as median (range). RESULTS: There were 19 completed center forms from 12 different countries. Annual (new) caseload varied with 10 centers reported seeing ≤5 patients/year and 4 centers >15 patients/year. The distribution of BA variants was isolated BA (80 [60-100]%), syndromic BA (10 [3-35]%), cystic BA (5 [1-15]%), and cytomegalovirus (CMV) immunoglobulin M (IgM)-positive BA (5 [0-15]% (CMV serology only formally tested in 16 centers). The commonest age group at KPE was 51 to 60 days (n = 8). All centers performed an exclusively open KPE, although one used laparoscopy for diagnosis. A steroid-based postoperative regimen was used in 11/19 (58%) centers, but with marked variation in dose and duration. Commonest perioperative antibiotics were a combination of piperacillin-tazocin (n = 7) and gentamicin (n = 8). Oral prophylactic antibiotics, with varying duration (4-52 weeks) were used in 13/19 (68%) centers. If CMV serology was positive, seven centers would treat with specific antiviral therapy. Other postoperative medication included ursodeoxycholic acid (UDCA) (n = 19), phenobarbitone (n = 4), and cholestyramine (n = 2). Self-declared clearance of jaundice in centers varied from 30 to 40% (n = 3) to > 60% (n = 5). CONCLUSION: All surveyed European centers continue to perform an exclusively open KPE, but there is no consensus on a standard adjuvant drug regimen. Self-declared outcome post-KPE also appears to be variable though the reasons are obscure.

A review of fatal road traffic accidents in Singapore from 2000 to 2004.

INTRODUCTION: This retrospective study aims to assess the epidemiology of road traffic accident (RTA) fatalities in Singapore, other causes of death besides trauma in a RTA, and identify the groups at risk. MATERIALS AND METHODS: Data of 1038 RTA fatalities were reported between 2000 and 2004. Analyses using the Fisher's exact test for discrete variables and multivariate Cox regression analysis were performed to identify groups at risk. The risk of fatality was measured using the prevalence rate ratio (PRR). RESULTS: The median age of victims in the sample was 36 years (interquartile range 24 to 55). Eight hundred and thirty six cases (78%) were in the economically productive age range of 15 to 65 years. Over the 5-year period, there was a preponderance of males. Majority of fatalities involved multiple injuries. There were also 64 (6.2%) and 25 (2.4%) cases of RTA fatalities from infective and cardiovascular (CVS) causes, respectively. Multivariate analyses showed that those > or = 60 years were 4 (95% CI of PRR, 3.04 to 5.43) times as likely to be pedestrian fatalities. Conversely, the risk of fatalities involving pedestrians and cyclists was reduced for males (PRR = 0.58; 95% CI, 0.46 to 0.73). However, males were at increased risk of fatalities involving motorcyclists, scooter and pillion riders (PRR = 1.96; 95% CI, 1.43 to 2.70), whereas such risk was reduced for those aged 30 to 59 (PRR = 0.70; 95% CI, 0.58 to 0.85) or > or = 60 years (PRR = 0.30; 95% CI, 0.21 to 0.42), respectively. CONCLUSION: As such, it appears that the groups at-risk had varying demographic characteristics. Public education could be modified to target these different groups to reduce the number of fatalities.