Systemic acute-phase response after laparoscopic and open cholecystectomy

Artificial intelligence-based analysis of associations between learning curve and clinical outcomes in endoscopic and microsurgical lumbar decompression surgery

PURPOSE

A common spine surgery procedure involves decompression of the lumbar spine. The impact of the surgeon's learning curve on relevant clinical outcomes is currently not well examined in the literature. A variety of machine learning algorithms have been investigated in this study to determine how a surgeon's learning curve and other clinical parameters will influence prolonged lengths of stay (LOS), extended operating times (OT), and complications, as well as whether these clinical parameters can be reliably predicted.

METHODS

A retrospective monocentric cohort study of patients with lumbar spinal stenosis treated with microsurgical (MSD) and full-endoscopic (FED) decompression was conducted. The study included 206 patients with lumbar spinal stenosis who underwent FED (63; 30.6%) and MSD (118; 57.3%). Prolonged LOS and OT were defined as those exceeding the 75th percentile of the cohort. Furthermore, complications were assessed as a dependent variable. Using unsupervised learning, clusters were identified in the data, which helped distinguish between the early learning curve (ELC) and the late learning curve (LLC). From 15 algorithms, the top five algorithms that best fit the data were selected for each prediction task. We calculated the accuracy of prediction (Acc) and the area under the curve (AUC). The most significant predictors were determined using a feature importance analysis.

RESULTS

For the FED group, the median number of surgeries with case surgery type at the time of surgery was 72 in the ELC group and 274 in the LLC group. FED patients did not significantly differ in outcome variables (LOS, OT, complication rate) between the ELC and LLC group. The random forest model demonstrated the highest mean accuracy and AUC across all folds for each classification task. For OT, it achieved an accuracy of 76.08% and an AUC of 0.89. For LOS, the model reached an accuracy of 83.83% and an AUC of 0.91. Lastly, in predicting complications, the random forest model attained the highest accuracy of 89.90% and an AUC of 0.94. Feature importance analysis indicated that LOS, OT, and complications were more significantly affected by patient characteristics than the surgical technique (FED versus MSD) or the surgeon's learning curve.

CONCLUSIONS

A median of 72 cases of FED surgeries led to comparable clinical outcomes in the early learning curve phase compared to experienced surgeons. These outcomes seem to be more significantly affected by patient characteristics than the learning curve or the surgical technique. Several study variables, including the learning curve, can be used to predict whether lumbar decompression surgery will result in an increased LOS, OT, or complications. To introduce the provided prediction tools into clinics, the algorithms need to be implemented into open-source software and externally validated through large-scale randomized controlled trials.

In primary total hip arthroplasty, the direct anterior approach leads to higher levels of creatine kinase and lower levels of C-reactive protein compared to the posterolateral approach: a propensity score matching analysis of short-term follow-up data

BACKGROUND

This retrospective study compares the invasiveness of the direct anterior approach (DAA) and the posterolateral approach (PLA) in total hip arthroplasty (THA) by assessing three widely used inflammation-related serum markers in the first ten post-operative days.

METHODS

The database of our institution was mined for primary THAs conducted by the DAA or the PLA from February 2020 to June 2022. Demographics and creatine kinase (CK), C-reactive protein (CRP), and white blood cells were compared. Propensity Score Matching (PSM) analysis (1:1 ratio) was conducted based on multiple variables.

RESULTS

PSM analysis yielded 44 pairs of DAA and PLA patients. CK was significantly higher (p < 0.001) in the DAA than in the PLA group on postoperative day (POD) 2, 5 and 10. The POD2, POD5 and POD10 CK/preoperative CK ratio was 12.9, 5.0 and 0.8 in DAA and 8.8, 3.3 and 0.6 in PLA (p = 0.017, p = 0.012 and p = 0.025, respectively). The POD2, POD5 and POD10 CRP/preoperative CRP ratio was 95.1, 65.6 and 22.8 in PLA and 34.7, 23.3 and 8.9 in DAA (p < 0.001, p = 0.002 and p < 0.001, respectively).

CONCLUSION

PSM analysis of early postoperative CK and CRP values demonstrated that the DAA should be considered as a less stressful approach, not as a muscle-sparing or a minimally invasive THA approach.

Video-based training of situation awareness enhances minimally invasive surgical performance: a randomized controlled trial

BACKGROUND

Many training curricula were introduced to deal with the challenges that minimally invasive surgery (MIS) presents to the surgeon. Situational awareness (SA) is the ability to process information effectively. It depends on general cognitive abilities and can be divided into three steps: perceiving cues, linking cues to knowledge and understanding their relevance, and predicting possible outcomes. Good SA is crucial to predict and avoid complications and respond efficiently. This study aimed to introduce the concept of SA into laparoscopic training.

METHODS

This is a prospective, randomized, controlled study conducted at the MIS Training Center of Heidelberg University Hospital. Video sessions showing the steps of the laparoscopic cholecystectomy (LC) were used for cognitive training. The intervention group trained SA with interposed questions inserted into the video clips. The identical video clips, without questions, were presented to the control group. Performance was assessed with validated scores such as the Objective Structured Assessment of Technical Skills (OSATS) during LC.

RESULTS

72 participants were enrolled of which 61 were included in the statistical analysis. The SA-group performed LC significantly better (OSATS-Score SA: 67.0 ± 11.5 versus control: 59.1 ± 14.0, p value = 0.034) and with less errors (error score SA: 3.5 ± 1.9 versus control: 4.7 ± 2.0, p value = 0.027). No difference in the time taken to complete the procedure was found. The benefit assessment analysis showed no difference between the groups in terms of perceived learning effect, concentration, or expediency. However, most of the control group indicated retrospectively that they believed they would have benefitted from the intervention.

CONCLUSION

This study suggests that video-based SA training for laparoscopic novices has a positive impact on performance and error rate. SA training should thus be included as one aspect besides simulation and real cases in a multimodal curriculum to improve the efficiency of laparoscopic surgical skills training.

Performance of Artificial Intelligence-Based Algorithms to Predict Prolonged Length of Stay after Lumbar Decompression Surgery

Background: Decompression of the lumbar spine is one of the most common procedures performed in spine surgery. Hospital length of stay (LOS) is a clinically relevant metric used to assess surgical success, patient outcomes, and socioeconomic impact. This study aimed to investigate a variety of machine learning and deep learning algorithms to reliably predict whether a patient undergoing decompression of lumbar spinal stenosis will experience a prolonged LOS. Methods: Patients undergoing treatment for lumbar spinal stenosis with microsurgical and full-endoscopic decompression were selected within this retrospective monocentric cohort study. Prolonged LOS was defined as an LOS greater than or equal to the 75th percentile of the cohort (normal versus prolonged stay; binary classification task). Unsupervised learning with K-means clustering was used to find clusters in the data. Hospital stay classes were predicted with logistic regression, RandomForest classifier, stochastic gradient descent (SGD) classifier, K-nearest neighbors, Decision Tree classifier, Gaussian Naive Bayes (GaussianNB), support vector machines (SVM), a custom-made convolutional neural network (CNN), multilayer perceptron artificial neural network (MLP), and radial basis function neural network (RBNN) in Python. Prediction accuracy and area under the curve (AUC) were calculated. Feature importance analysis was utilized to find the most important predictors. Further, we developed a decision tree based on the Chi-square automatic interaction detection (CHAID) algorithm to investigate cut-offs of predictors for clinical decision-making. Results: 236 patients and 14 feature variables were included. K-means clustering separated data into two clusters distinguishing the data into two patient risk characteristic groups. The algorithms reached AUCs between 67.5% and 87.3% for the classification of LOS classes. Feature importance analysis of deep learning algorithms indicated that operation time was the most important feature in predicting LOS. A decision tree based on CHAID could predict 84.7% of the cases. Conclusions: Machine learning and deep learning algorithms can predict whether patients will experience an increased LOS following lumbar decompression surgery. Therefore, medical resources can be more appropriately allocated to patients who are at risk of prolonged LOS.

Inflammatory Biomarker Levels After Propofol or Sevoflurane Anesthesia: A Meta-analysis

BACKGROUND

The perioperative inflammatory response may be implicated in adverse outcomes including neurocognitive dysfunction and cancer recurrence after oncological surgery. The immunomodulatory role of anesthetic agents has been demonstrated in vitro; however, its clinical relevance is unclear. The purpose of this meta-analysis was to compare propofol and sevoflurane with respect to biomarkers of perioperative inflammation. The secondary aim was to correlate markers of inflammation with clinical measures of perioperative cognition.

METHODS

Databases were searched for randomized controlled trials examining perioperative inflammation after general anesthesia using propofol compared to sevoflurane. Inflammatory biomarkers investigated were interleukin (IL)-6, IL-10, tissue necrosis factor alpha (TNF-α), and C-reactive protein (CRP). The secondary outcome was incidence of perioperative neurocognitive disorders. Meta-analysis with metaregression was performed to determine the difference between propofol and sevoflurane.

RESULTS

Twenty-three studies were included with 1611 participants. Studies varied by surgery type, duration, and participant age. There was an increase in the mean inflammatory biomarker levels following surgery, with meta-analysis revealing no difference in effect between propofol and sevoflurane. Heterogeneity between studies was high, with surgery type, duration, and patient age contributing to the variance across studies. Only 5 studies examined postoperative cognitive outcomes; thus, a meta-analysis could not be performed. Nonetheless, of these 5 studies, 4 reported a reduced incidence of cognitive decline associated with propofol use.

CONCLUSIONS

Surgery induces an inflammatory response; however, the inflammatory response did not differ as a function of anesthetic technique. This absence of an effect suggests that patient and surgical variables may have a far more significant impact on the postoperative inflammatory responses than anesthetic technique. The majority of studies assessing perioperative cognition in older patients reported a benefit associated with the use of propofol; however, larger trials using homogenous outcomes are needed to demonstrate such an effect.

Do serum markers correlate with invasiveness of the procedure in THA? A prospective randomized study comparing direct anterior and lateral approaches

BACKGROUND

Advantages of minimally invasive approaches for total hip arthroplasty are still matter of debate. Serum markers have been assessed as objective method to quantify muscle damage after surgery but in literature ambiguous results have been reported. The aim of this prospective randomized study was to: 1) compare serum markers elevation between a minimally invasive direct anterior approach (DAA) and a direct lateral approach (DLA); 2) to establish a correlation between serum markers increase and other perioperative variables.

HYPOTHESIS

A lesser elevation of markers could be found in patients who underwent a minimally invasive DAA.

PATIENTS AND METHODS

Seventy patients were enrolled and randomly divided in two groups according to the type of the approach. All patients were treated with the same implant by the same surgeon and received the same rehabilitation protocol. Demographic data, preoperative Harris Hip Score (HHS) and operative time were recorded. Myoglobin, creatine kinase MB (CK-MB), troponin I, C-reactive protein (CRP), haemoglobin (HB) and pain levels were measured pre- and postoperatively.

RESULTS

Mean postoperative rise were 524.9±134.6 and 667.8±409.5 for myoglobin, 4.8±2.5 and 6.6±3.7 for CK-MB, and 16.9±5.3 and 15.4±6.4 for PCR, in DAA and DLA groups, respectively. In both groups, postoperatively values were significantly higher than preoperatively (p<0.05). Comparing the two groups, no significant differences in serum markers elevations were found. A significantly lower postoperative pain was found in DAA group than in DLA group (2.9 vs. 4.2 and 2.7 vs. 3.6 in second and third day, respectively (p<0.05)). No significant correlation was present between the serum marker elevations and age, BMI, HHS, operative time, HB or pain levels (p>0.05).

CONCLUSION

Serum markers of muscle damage and inflammation increased in the postoperative period without significant differences between DAA and DLA, even though overall trend was higher in DLA group. The DAA group had significantly lower levels of postoperative pain. No significant correlation between pain and serum markers levels was found.

LEVEL OF EVIDENCE

I; randomized study.

Delayed cytokine release syndrome after neoadjuvant nivolumab: a case report and literature review

Aim: Cytokine release syndrome (CRS) is an infrequently described immune-related adverse event of checkpoint inhibitors (CPI). CPI-induced CRS typically presents with fevers, hemodynamic instability and organ dysfunction within 2 weeks of the last treatment cycle. Case study: We report an unusual case of delayed and severe CRS occurring postoperatively in a patient with hepatic-limited metastatic colorectal cancer who received neoadjuvant immunotherapy. After a negative workup for alternative causes, he received prolonged corticosteroid treatment with symptom resolution. Conclusion: CPI-induced CRS can mimic sepsis and clinicians should maintain a high-index of suspicion to diagnose this immune-related adverse event early and initiate appropriate treatment. As use of perioperative immunotherapy increases, the potential role of surgery to trigger CRS in this case warrants further investigation.

A prospective randomized controlled trial comparing the systemic inflammatory response in conventional jig-based total knee arthroplasty versus robotic-arm assisted total knee arthroplasty

AIMS

The primary aim of this study was to compare the postoperative systemic inflammatory response in conventional jig-based total knee arthroplasty (conventional TKA) versus robotic-arm assisted total knee arthroplasty (robotic TKA). Secondary aims were to compare the macroscopic soft tissue injury, femoral and tibial bone trauma, localized thermal response, and the accuracy of component positioning between the two treatment groups.

METHODS

This prospective randomized controlled trial included 30 patients with osteoarthritis of the knee undergoing conventional TKA versus robotic TKA. Predefined serum markers of inflammation and localized knee temperature were collected preoperatively and postoperatively at six hours, day 1, day 2, day 7, and day 28 following TKA. Blinded observers used the Macroscopic Soft Tissue Injury (MASTI) classification system to grade intraoperative periarticular soft tissue injury and bone trauma. Plain radiographs were used to assess the accuracy of achieving the planned postioning of the components in both groups.

RESULTS

Patients undergoing conventional TKA and robotic TKA had comparable changes in the postoperative systemic inflammatory and localized thermal response at six hours, day 1, day 2, and day 28 after surgery. Robotic TKA had significantly reduced levels of interleukin-6 (p < 0.001), tumour necrosis factor-α (p = 0.021), ESR (p = 0.001), CRP (p = 0.004), lactate dehydrogenase (p = 0.007), and creatine kinase (p = 0.004) at day 7 after surgery compared with conventional TKA. Robotic TKA was associated with significantly improved preservation of the periarticular soft tissue envelope (p < 0.001), and reduced femoral (p = 0.012) and tibial (p = 0.023) bone trauma compared with conventional TKA. Robotic TKA significantly improved the accuracy of achieving the planned limb alignment (p < 0.001), femoral component positioning (p < 0.001), and tibial component positioning (p < 0.001) compared with conventional TKA.

CONCLUSION

Robotic TKA was associated with a transient reduction in the early (day 7) postoperative inflammatory response but there was no difference in the immediate (< 48 hours) or late (day 28) postoperative systemic inflammatory response compared with conventional TKA. Robotic TKA was associated with decreased iatrogenic periarticular soft tissue injury, reduced femoral and tibial bone trauma, and improved accuracy of component positioning compared with conventional TKA. Cite this article: Bone Joint J 2021;103-B(1):113-122.

The Inflammatory Response to Surgery in Sickle Cell Disease Patients Undergoing Cholecystectomy

Background and Objectives:

Patients with sickle cell anemia (SCA) may have elevated inflammatory markers in health, and this may be heightened after open operations. The inflammatory response of patients with SCA after minimally invasive surgeries has not been fully explored.

Patients and Methods:

Consecutive patients with SCA and with hemoglobin AA (HbAA) undergoing laparoscopic cholecystectomy for acute cholecystitis were recruited into the study. Blood samples were taken before induction of anesthesia (0-h); at 4, 12, 24, and 48 h; and on postoperative day 7. Samples were analyzed for serum C-reactive protein and interleukin (IL)-1 through IL-18.

Results:

Twenty-three patients, including 9 with SCA and 14 with HbAA, were recruited with 4 cases performed by open laparotomy. At 0-h, proinflammatory IL-1 levels (6.1 versus 4.8) and C-reactive protein levels (32.5 versus 26.6) were higher in patients with hemoglobin SS (HbSS) than in patients with HbAA, respectively. Over time, inflammatory markers were generally higher at each time-point for patients with HbSS compared with patients with HbAA for both proinflammatory and anti-inflammatory cytokines, rising immediately after surgery and up to 48 hours, then returning to baseline by postoperative day 7. There was a higher mean IL-1 level across all time-points in the HbSS group than in the HbAA group (P = .04).

Conclusion:

This exploratory study found an enhanced inflammatory response to cholecystectomy in patients with SCA compared with patients with HbAA. Minimally invasive surgical strategies for this patient group may help to mediate this response.

The Length of Surgical Skin Incision in Postoperative Inflammatory Reaction

Background and Objectives:

Surgery provokes inflammatory and immune responses, so efforts have been made to reduce host response by using less invasive techniques. The purpose of this experimental study was to investigate the surgical stress induced by skin incision and the role of liver response in this process.

Methods:

Seventy male anesthetized Wistar rats were subjected to a midline incision confined strictly to the skin (dermis) of either 1 cm long (n = 20), 10 cm long (n = 20), or no incision (n = 20) or served as controls (n = 10). Skin trauma was left open for a 20-minutes period, and then was meticulously sutured. At 3 and 24 hours later, laparotomy was performed on half the rats of each group, for blood and liver sampling. In serum and liver homogenates, cytokine-induced neutrophil chemoattractant (CINC)1/interleukin (IL)-8 and tumor necrosis factor (TNF)-α levels were measured with enzyme-linked immunosorbent assays and nitric oxide (NO) using a Griess reaction.

Results:

Skin trauma was found to significantly (P < .01) increase all inflammatory mediators tested (CINC1/IL-8, TNF-α, NO) in serum of operated rats versus controls, the increase being proportionally dependent on the length of skin incision. In liver homogenates, CINC1/IL-8 was significantly (P < .01) increased in operated animals versus controls, similarly to serum levels. In contrast, liver TNF-α levels were inversely related to serum levels, and a significant (P < .01) decrease in TNF-α was observed in liver homogenates of operated animals compared with the controls, indicating that the increased TNF-α in blood reflects liver TNF-α secretion.

Conclusion:

Our findings suggest that inflammatory and immune reactions induced by skin-only surgical trauma are closely correlated to the length of skin incision.

Comparison of acute kidney injury between open and laparoscopic pylorus-preserving pancreaticoduodenectomy: Propensity score analysis

Laparoscopic pylorus-preserving pancreaticoduodenectomy is being performed more frequently because of improved surgical techniques. Although several studies have demonstrated safety and favourable outcomes of laparoscopic pylorus-preserving pancreaticoduodenectomy compared to open pylorus-preserving pancreaticoduodenectomy, few studies have focused on the development of postoperative acute kidney injury. This retrospective study compared the prevalence and risk factors of acute kidney injury following laparoscopic and open pylorus-preserving pancreaticoduodenectomy. Data from 809 patients who underwent pylorus-preserving pancreaticoduodenectomy between February 2012 and September 2016 were analysed. Patients were divided into two groups according to the surgical procedure (open pylorus-preserving pancreaticoduodenectomy [n = 632] vs laparoscopic pylorus-preserving pancreaticoduodenectomy [n = 177]). The Kidney Disease: Improving Global Outcomes criteria were used to define postoperative acute kidney injury and risk factors were investigated using multivariable logistic regression analysis with propensity score matching analysis and standardized mortality ratio weighting to compare outcomes. No significant differences were found in the occurrence of postoperative acute kidney injury and incidence of postoperative ICU admission between open and laparoscopic pylorus-preserving pancreaticoduodenectomy groups after propensity score matching (p = 1.000, p = 0.999, respectivelyand standardized mortality ratio weighted analysis (p = 0.619, p = 0.982, respectively). Hospital stay was significantly shorter in the laparoscopic pylorus-preserving pancreaticoduodenectomy group (propensity matched set, mean [SD], 16.7 [10.0] vs. 18.7 [9.6] days, p = 0.004; standardized mortality ratio, 16.6 [9.9] vs. 18.1 [8.8] days, p = 0.001). There was no significant difference in postoperative acute kidney injury incidence between both groups. Laparoscopic pylorus-preserving pancreaticoduodenectomy is promising with comparable postoperative outcomes to open pylorus-preserving pancreaticoduodenectomy and has the advantage of shorter hospital stay.

Hydrogen protects against liver injury during CO2 pneumoperitoneum in rats

The aim of the current study was to identify the protective effect of hydrogen gas against liver injury during CO₂ pneumoperitoneum. Rats were randomly divided into three groups: control group (C group), pneumoperitoneum group (P15 group) and hydrogen group (H₂ group). Rats in the C group were subjected to anesthesia for 90 min. Rats in the P15 group received an abdominal insufflation of CO₂ for 90 min at an intra-abdominal pressure of 15 mmHg. Rats in the H₂ group received a hypodermic injection of hydrogen gas (0.2 mL/kg) and after 10 min they received an abdominal insufflation of CO₂ for 90 min at an intra-abdominal pressure of 15 mmHg. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were measured to evaluate liver function. Malondialdehyde (MDA), superoxide dismutase (SOD) and glutathione (GSH) content were measured to evaluate oxidative stress. Nuclear factor E2-related factor 2 (Nrf2) and Nrf2 downstream target genes, apoptosis-related genes and inflammatory cytokine mRNA and protein expression were detected. Liver injury was detected under the microscope. Our results revealed that liver function, antioxidants content, inflammation and liver injury were improved after hydrogen preconditioning in H₂ group compared with P15 group. Overall, our results revealed that subcutaneous hydrogen injection could exert a protective effect against liver injury during CO₂ pneumoperitoneum through reducing oxidative stress, cell apoptosis and inflammatory cytokines release.

Comparison of acute kidney injury between open and laparoscopic liver resection: Propensity score analysis

The inflammatory response has been shown to be a major contributor to acute kidney injury. Considering that laparoscopic surgery is beneficial in reducing the inflammatory response, we compared the incidence of postoperative acute kidney injury between laparoscopic liver resection and open liver resection. Among 1173 patients who underwent liver resection surgery, 222 of 926 patients who underwent open liver resection were matched with 222 of 247 patients who underwent laparoscopic liver resection, by using propensity score analysis. The incidence of postoperative acute kidney injury assessed according to the creatinine criteria of the Kidney Disease: Improving Global Outcomes definition was compared between those 1:1 matched groups. A total 77 (6.6%) cases of postoperative acute kidney injury occurred. Before matching, the incidence of acute kidney injury after laparoscopic liver resection was significantly lower than that after open liver resection [1.6% (4/247) vs. 7.9% (73/926), P < 0.001]. After 1:1 matching, the incidence of postoperative acute kidney injury was still significantly lower after laparoscopic liver resection than after open liver resection [1.8% (4/222) vs. 6.3% (14/222), P = 0.008; odds ratio 0.273, 95% confidence interval 0.088-0.842, P = 0.024]. The postoperative inflammatory marker was also lower in laparoscopic liver resection than in open liver resection in matched set data (white blood cell count 12.7 ± 4.0 × 103/μL vs. 14.9 ± 3.9 × 103/μL, P < 0.001). Our findings suggest that the laparoscopic technique, by decreasing the inflammatory response, may reduce the occurrence of postoperative acute kidney injury during liver resection surgery.

A randomized controlled trial for evaluation of lower abdominal laparoscopic cholecystectomy

BACKGROUND

To improve minimally invasive outcomes, we designed a new procedure, lower abdominal laparoscopic cholecystectomy (LALC). This study was conducted to evaluate the effects of LALC versus classical (CLC) and single-incision (SILC) laparoscopic cholecystectomy on reducing systemic acute inflammatory response, improving cosmesis, and postoperative pain relief.

MATERIAL AND METHODS

Beginning from July 2014, 105 patients meeting the inclusion criteria were randomly assigned to three groups: LALC, CLC, and SILC. The primary endpoint was the determination of systemic inflammatory response to the surgery. Other outcome measures included cosmesis, postoperative pain, and perioperative indices.

RESULTS

Each of the three groups consisted of 35 patients. The duration of the operation was significantly longer in the SILC group (p= .005). The rates of adverse events were similar. Changes in interleukin-6 (p =  .001) and tumor-necrosis factor-α (p =  .016) measured before and after surgery differed significantly; patients who underwent LALC had the smallest change in inflammatory response. Cosmesis scores at one (p =  .002) and 12 (p =  .004) weeks after surgery favored LALC and SILC. Significant differences in pain scores at four (p =  .011) and 12 h (p =  .024) postoperatively were also observed.

CONCLUSIONS

In selected patients, LALC shows more advantages in terms of lower systemic inflammatory response, improved cosmesis, and a favorable postoperative pain profile when compared with CLC and SILC.

No Correlation Between Serum Markers and Early Functional Outcome After Contemporary THA

BACKGROUND

Serum markers of inflammation and muscle damage have shown clinical utility in some areas of medicine, but their value in determining the invasiveness or in predicting the early functional outcomes after total hip arthroplasty (THA) has not been demonstrated.

QUESTIONS/PURPOSES

(1) Do serum markers of inflammation/muscle damage predict pain or early functional outcomes after contemporary THA performed through a direct anterior or miniposterior approach? (2) Do early functional outcomes as measured by in-hospital outcomes and clinical milestones differ between a contemporary direct anterior and miniposterior approach for THA?

METHODS

Between August 31, 2013, and September 1, 2014, all patients presenting as candidates for THA at our institution who had not already had preoperative blood draws (161) were recruited for this study. Forty-two patients failed these exclusion criteria, eight patients declined enrollment, and 11 were consented but did not complete the required preoperative blood tests. Recruitment stopped when 50 patients had been enrolled in both the direct anterior group and the miniposterior group (2n = 100) based on a priori power analysis. One high-volume surgeon performed all of the direct anterior approaches and three high-volume surgeons performed the miniposterior approaches. Groups did not differ with the numbers available in mean age (63 years; SD 10; range, 35-86 years), sex (52% female), or mean body mass index (mean 31 kg/m²; SD 7 kg/m²; range, 20-73 kg/m²). Serum markers measured including hemoglobin, hematocrit, myoglobin, creatine kinase (CK), C-reactive protein, interleukin-6, and tumor necrosis factor-α were collected at the preoperative clinic visit and on postoperative days 1 and 2 and compared with operative details, in-hospital complications, therapy progress, pain scores, and functional results from a milestone diary. Functional results evaluated included time to discontinue all narcotics and gait aids, independence with activities of daily living, return to driving a motor vehicle, and return to work.

RESULTS

Serum markers after contemporary THA were not correlated with early functional outcomes either in-hospital or postdischarge. Specifically, no serum marker was predictive of the time to discontinue gait aids or narcotics, return to driving, climb stairs, or independence in activities of daily living (all p > 0.08). The patients receiving the direct anterior approach did have lesser elevations of CK levels than the patients undergoing the miniposterior approach (436 ± 312 [direct anterior {DA}] versus 1071 ± 459 [miniposterior {MP}], difference in means: -635; 95% confidence interval [CI], -809 to -462; p < 0.001), myoglobin levels (168 ± 114 [DA] versus 378 ± 151 [MP], difference in means: -210, 95% CI, -269 to -151; p < 0.001), C-reactive protein (79 ± 57 [DA] versus 124 ± 58 [MP], difference in means: -46, 95% CI, -71 to -21; p < 0.001), and interleukin-6 (45 ± 34 [DA] versus 80 ± 53 [MP], difference in means: -35, 95% CI, -54 to -16; p < 0.001), but not in other serum markers. In the hospital, patients undergoing the direct anterior approach ambulated 35 steps farther with physical therapy (178 feet DA versus 142 feet MP, p < 0.01, difference in means: 35, 95% CI, 9-62; p = 0.009) and had visual analog scale pain scores 1.1 less (4.8 DA versus 5.9 MP, difference in means: -1.1, 95% CI, 2.0 to -0.2; p = 0.02) than patients undergoing the miniposterior approach. There were no differences between approaches in other in-hospital outcomes or in posthospital clinical milestones.

CONCLUSIONS

Serum markers including CK, myoglobin, C-reactive protein, interleukin-6, and tumor necrosis factor-α did not predict early pain/function after contemporary THA approaches. Although lesser elevations in myoglobin, CK, C-reactive protein, and interleukin-6 were found after direct anterior THA, that difference was not clinically meaningful. Further reporting of serum biomarkers as a measure of physiological burden after orthopaedic surgical procedures should be viewed as suspect until clear linear or threshold values are established.

LEVEL OF EVIDENCE

Level III, diagnostic study.

The Effect of Air Tourniquet on Interleukin-6 Levels in Total Knee Arthroplasty

Background:

Air tourniquet-induced skeletal muscle injury increases the concentrations of some cytokines such as interleukin-6 (IL-6) in plasma. However, the effect of an air tourniquet on the IL-6 concentrations after total knee arthroplasty (TKA) is unclear. We therefore investigated the impact of tourniquet-induced ischemia and reperfusion injury in TKA using the IL-6 level as an index.

Methods:

Ten patients with primary knee osteoarthrosis who underwent unilateral TKA without an air tourniquet were recruited (Non-tourniquet group). We also selected 10 age- and sex-matched control patients who underwent unilateral TKA with an air tourniquet (Tourniquet group). Venous blood samples were obtained at 3 points; before surgery, 24 h after surgery, and 7 days after surgery.

The following factors were compared between the two groups; IL-6, C-reactive protein (CRP), creatine phosphokinase (CPK), the mean white blood cell (WBC) counts, and the maximum daily body temperatures.

Results:

The IL-6 level at 24 h after surgery was significantly higher than that at any other point (p<0.01). No significant differences were observed in the WBC count, the body temperature, or the CRP, CPK, or IL-6 levels of the two groups at any of the time points.

Conclusion:

The effect of ischemia and reperfusion due to the use of an air tourniquet on increasing the IL-6 level was much smaller than that induced by surgical stress in TKA.

Markers of muscle damage for comparing soft tissue injury following proximal femur nail and dynamic hip screw operations for intertrochanteric hip fractures

BACKGROUND

Femoral neck fractures are the most common fractures among the elderly. The two operative approaches used for the treatment of AO/OTA 31 intertrochanteric fractures include an intramedullary device (proximal femoral nail [PFN]) or an extramedullary device (sliding/dynamic hip screw [DHS]). The aim of this study was to provide objective evidence of local soft tissue injury by measuring serum creatine phosphokinase (CPK), a biochemical marker, to quantify muscle damage and inflammation in patients treated by the two approaches.

PATIENTS AND METHODS

Medical data of 359 patients operated for intertrochanteric fractures with PFN (156 patients) or DHS (193 patients) were retrospectively reviewed. The fractures were classified according to AO/OTA classification. Perioperative and radiographic data were collected to ensure cohorts with similar characteristics. Serum CPK and serum hemoglobin (Hb) levels were measured preoperatively and on postoperative day 1 (POD1). Independent predictors of elevation in the levels of markers of inflammation and muscle damage were determined by a multivariate linear regression model.

RESULTS

The demographics were similar for the two groups. Our study population included 64.2% female patients. Preoperative serum CPK levels were available for 89 patients and POD1 serum CPK levels were available for all patients. One-hundred and thirteen of the 193 DHS patients (58%) and 14 of the 156 PFN patients (9%) had a stable fracture (AO/OTA 31A1, p<0.0001). The DHS patients had a greater increase between pre- and postoperative CPK levels compared to the PFN patients (DHS, δ=368 versus PFN, δ=65, p<0.0002). The PFN patients had a greater decrease in both the pre- and postoperative Hb levels compared to the DHS patients (Diff_Hb 0.27g/dl). The older the patient, the greater decreases in Diff_CPK compared to the younger ones.

CONCLUSIONS

Implementation of POD1 CPK blood levels as a biochemical marker of soft tissue injury provided quantitative evidence that patients whose intertrochanteric fracture was stabilized by a DHS suffered greater soft tissue injury compared to patients whose fracture was stabilized by a PFN.

Tissue injuries after single-port and multiport laparoscopic gynecologic surgeries: A prospective multicenter study

The present study focused on the degree of tissue injury following single-port laparoscopic surgery (SPLS) and multiport laparoscopic surgery (MPLS) for the treatment of various benign gynecologic diseases. A total of 228 patients were prospectively enrolled at seven academic centers in South Korea between April 2011 and September 2012. Of these, 122 patients underwent SPLS and 106 patients underwent MPLS. The serum levels of C-reactive protein, creatine phosphokinase, lactic dehydrogenase and cancer antigen 125 were measured preoperatively and on postoperative day 4 by immunonephelometry. Cosmetic satisfaction and postoperative pain scores (visual analogue scale) were analyzed. Postoperative changes in the levels of the serum markers were found to be similar between the SPLS and MPLS groups. However, the postoperative pain scores at 48 h were significantly lower in the SPLS group when compared with those in the MPLS (P=0.001). In addition, patient-controlled analgesia was used more frequently by patients in the MPLS group (P=0.003). The present study is the first prospective investigation of tissue injury resulting from SPLS and MPLS in gynecology. In conclusion, the current study demonstrated that serum marker levels during SPLS were similar to those during MPLS in the treatment of benign gynecologic diseases. However, SPLS is a reasonable alternative to MPLS and is associated with comparable tissue injury, improved cosmesis and reduced postoperative pain.

Comparison of postoperative surgical stress following robotic thyroidectomy and open thyroidectomy: a prospective pilot study

BACKGROUND

Robotic thyroid surgery using the da Vinci surgical system has certain cosmetic advantages; however, the invasiveness of robotic thyroid surgery is still a concern to many surgeons. Previous research has not directly compared the surgical stress of robotic thyroidectomy with that of conventional open surgery. The aim of the present study was to evaluate surgical stress using postsurgical measurements of several clinical markers.

METHODS

A pilot study was performed to evaluate surgical stress following robotic and open thyroid surgery. A total of 29 papillary thyroid cancer patients from July to November 2014 were enrolled. Fourteen patients underwent conventional open surgery, and fifteen underwent robotic thyroidectomy. IL-6 levels, serum WBC counts, CRP levels, surgical plethysmographic index (SPI), and visual analogue scale (VAS) score were measured to compare surgical stress between the robotic and the open surgery groups.

RESULTS

No significant differences were seen between the two groups in IL-6 level, WBC count or CRP level (p = 0.380, 0.374, 0.360, respectively). Mean SPI level during the surgery was 41.9 ± 4.7 in open group compared to 39.5 ± 2.2 in robotic group, though this finding showed borderline significance (p = 0.095). VAS score after open surgery was significantly higher than after robotic operation (p = 0.048).

CONCLUSION

The results of this study suggest that robotic thyroidectomy can result in a less than equivocal systemic stress response than is seen in open thyroidectomy. However, further investigation including large-scale, prospective, multicenter studies is warranted for non-inferiority trials.

Laparoscopic Splenectomy and Azygoportal Disconnection: a Systematic Review

Background and Objectives:

Given the technical difficulty of laparoscopic splenectomy and azygoportal disconnection (LSD), data are limited that compare the laparoscopic to the open procedure. As the technique becomes more widespread, questions regarding its safety, feasibility, and reproducibility must be addressed. This review assesses the current status of LSD.

Methods:

We conducted our literature review with a search of the PubMed database. All published series of 5 or more laparoscopic splenectomy and azygoportal disconnection procedures were examined. The demographic, intraoperative, and postoperative data analyzed included number of ports, conversion rate, operative duration, estimated intraoperative blood loss, postoperative hospital stay, and complications.

Results:

Fifteen articles met the review criteria. Of 412 laparoscopic procedures, traditional laparoscopic splenectomy and azygoportal disconnection (TLSD) was used in 322 patients (78.2%), a modified laparoscopic procedure (MLSD) in 79 (19.2%), and a single-incision laparoscopic procedure (SLSD) in 11 (2.7%). Compared with the traditional and single-incision laparoscopic procedures, the MLSD procedure was associated with shorter operative duration and less blood loss. Furthermore, although the incidence of postoperative portal vein system thrombosis was higher in the laparoscopic than in the open splenectomy with azygoportal disconnection (OSD) procedure, the LSD procedure was associated with less pulmonary infection and pleural effusion and fewer incisional and overall complications than the open procedure. The rate of conversion to an open procedure was 5.4%.

Conclusions:

LSD is feasible and safe for selected patients when performed by an expert laparoscopic surgeon. It has perioperative advantages over OSD, but studies with longer follow-up periods and larger samples of patients are needed.

A prospective double-blinded randomized controlled trial comparing systemic stress response in Laparoascopic cholecystectomy between low-pressure and standard-pressure pneumoperitoneum

INTRODUCTION

Laparoscopic cholecystectomy (LC) has become the gold-standard treatment for gallstone diseases. However, despite huge reduction in operative injury, systemic stress response remains high. This randomized controlled trial (RCT) aimed to compare systemic stress response between 2 different techniques of CO2 pneumoperitoneum.

METHODS

Trough a prospective, double-blinded RCT, serum levels of cortisol, adrenaline, glucose, and C-reactive protein (CRP) were compared between the two groups consisted of 50 patients undergoing LC under low-pressure and standard-pressure CO2 pneimoperitoneum.

RESULTS

A total of fifty patients undergoing LC were equally assigned to 2 groups of twenty five patients. Average age was 48 ± 13.8 years (range, 19-74 years). Operative time was similar between standard-pressure group (47.8 ± 16.8 min) and low-pressure group (53.6 ± 25.1). Moreover, intra-operative IV volume administration and urine output did not differ significantly between the 2 groups (p > 0.05). Although the average heart rate and mean arterial pressure were slightly higher in a standard-pressure group compared with a low-pressure group, serial measurements of these parameters were statistically similar between the 2 groups. Serial changes of serum levels of cortisol, glucose, adrenaline, and CRP were compared between surgery day, postoperative 6-h and 1st postoperative day, which did not differ significantly between the standard-pressure and the low-pressure groups (p > 0.05).

CONCLUSION

Our study did not reveal any alteration in systemic stress response with reduction in intra-abdominal pressure of pneumoperitoneum in LC. RCT REGISTRATION: irct.ir ID: IRCT201110072982N5.

Hepatocytes as Immunological Agents

Hepatocytes are targeted for infection by a number of major human pathogens, including hepatitis B virus, hepatitis C virus, and malaria. However, hepatocytes are also immunological agents in their own right. In systemic immunity, they are central in the acute-phase response, which floods the circulation with defensive proteins during diverse stresses, including ischemia, physical trauma, and sepsis. Hepatocytes express a variety of innate immune receptors and, when challenged with pathogen- or damage-associated molecular patterns, can deliver cell-autonomous innate immune responses that may result in host defense or in immunopathology. Important human pathogens have evolved mechanisms to subvert these responses. Finally, hepatocytes talk directly to T cells, resulting in a bias toward immune tolerance.

Is robotic-assisted radical cystectomy (RARC) with intracorporeal diversion becoming the new gold standard of care?

BACKGROUND

Totally intracorporeal robotic-assisted radical cystectomy (RARC) has perceived difficulties compared to open radical cystectomy (ORC). As the technique is increasingly adopted around the world, the benefits of RARC with intra- or extracorporeal urinary diversion or ORC for the patients are still unclear. In this article, we consider the current evidence for this issue.

METHODS

We assessed two questions through using expert opinion and the medical literature: (A) Is RARC better than ORC for removing the cancer surgery and outcome? (B) Is RARC better than ORC for the urinary diversion?

OUTCOMES

(A) RARC is better than ORC for shorter length of stay, blood loss and complication rates. (B) Intracorporeal orthotopic neobladder may have a significant physiological and surgical benefit to the patient recovery.

CONCLUSIONS

RARC with total intracorporeal reconstruction has potential benefits to the patient. We recommend that all surgeons document patient-related outcome measures, urodynamics and enhanced recovery protocols for cystectomy patients to help us understand the real improvements within bladder cancer surgery and reconstruction.

Evaluation of systemic inflammatory responses in cholecystectomy by means of access. Single-port umbilical incision, transvaginal NOTES, laparoscopy and laparotomy

PURPOSE

To evaluate and compare clinical and inflammatory responses to the surgical trauma caused by cholecystectomy via several access approaches: single-port umbilical incision (SILS), transvaginal natural orifice transluminal endoscopic surgery (NOTES), laparoscopy, and Laparotomy.

METHODS

Twenty-eight female pigs were equally divided into four groups and submitted to cholecystectomy by single-port umbilical incision, transvaginal NOTES, laparoscopy, or Laparotomy. An additional five animals served as controls (sham group). Animals were monitored perioperatively regarding anesthesia and surgical procedure times, as well as for the presence of complications. Postoperatively, they were evaluated regarding time to ambulation and feeding, and the presence of clinical events. Procalcitonin, C-reactive protein (CRP), and AQUI feron-gamma (IFN-γ) measurements were performed before surgery and immediately, two days, and seven days after surgery. Animals were sacrificed and necropsied at seven days after surgery.

RESULTS

All procedures were successfully performed as proposed in each group. Only minor complications, such as gallbladder perforation and bleeding from the liver bed, were observed during surgery in all groups. The vaginal NOTES group showed higher anesthesia and surgical procedure times compared to the other groups (p<0.001). No other between-group differences in perioperative or postoperative times, clinical evolution, or serum inflammatory markers were observed. Only adhesions were found on necropsy, with no differences between groups.

CONCLUSION

The single-port umbilical and transvaginal NOTES access approaches were feasible and safe compared to laparoscopic and laparotomy for cholecystectomy.

Biomolecular inflammatory response to surgical energy usage in laparoscopic surgery: results of a randomized study

OBJECTIVE

Use of surgical energy is integral to laparoscopic surgery (LS). Energized dissection (ED) has a potential to impact the biomolecular expression of inflammation due to ED-induced collateral inflammation. We did this triple-blind randomized controlled (RCT) study to assess this biomolecular footprint in an index LS, i.e., laparoscopic cholecystectomy (LC).

METHODS AND PROCEDURES

This RCT was conducted in collaboration with tertiary-level institutions, from January 2014 to December 2014 with institutional review board clearance. Consecutive, unselected, consenting candidates for LC were randomized (after anesthesia induction) into group I (ED) and group II (non-ED). They were managed with compliance to universal protocols for ethics, informed consent, anesthesia, drug usage and clinical pathway with blinded observers. Biomolecular inflammatory markers, i.e., interleukin 6 (IL-6), tumor necrosis factor-alpha (TNF-α) and highly sensitive CRP (HS-CRP), were measured with blood drawn juxta-preoperatively (H0), at 4 h (H4) and at 24 h (H24). The quantitative changes induced by ED on IL-6, TNF-α and HS-CRP at H0, H4 and H24 with their kinetic behavior were the study endpoint. Prospective data were analyzed statistically with a p value of <0.05 being significant.

RESULTS

Two cases from the ED group had biliary injury and hence were withdrawn from analysis. The ED (n = 49) and non-ED (n = 51) groups had similar demographic, clinical and H0 biomolecular variables. There was a significant increase in IL-6, TNF-α and HS-CRP from H0 to H4 in both the groups (p values <0.001). From H4 to H24, all three cytokines showed significant increase in ED group (p < 0.05), whereas in the non-ED group, IL-6 showed significant fall (p = 0.004) and TNF-α showed no significant change (p = 0.063). Both the groups showed H4-H24 elevation of HS-CRP (p = 0.000).

CONCLUSION

Energized dissection adds to the cytokine-mediated postoperative inflammation. The additional ED-induced inflammation can be measured objectively by IL-6 and TNF-α levels.

CLINICAL TRIALS REGISTRY

Clinical Trials Registry, India (REF/2014/06/007153).

Surgical approach in primary total hip arthroplasty: anatomy, technique and clinical outcomes

Total hip arthroplasty (THA) has revolutionized the treatment of hip arthritis. A number of surgical approaches to the hip joint exist, each with unique advantages and disadvantages. The most commonly used approaches include the direct anterior, direct lateral and posterior approaches. A number of technical intricacies allow safe and efficient femoral and acetabular reconstruction when using each approach. Hip dislocation, abductor insufficiency, fracture and nerve injury are complications of THA, although their relative risk varies by approach. Numerous clinical trials have sought to elicit differences in patient-reported outcomes, complication rates and return to function among the surgical approaches. This review outlines some of the technical pearls of performing a THA through either a direct anterior, direct lateral or posterior approach. A literature review outlines the impact of surgical approach on clinical outcomes and clinically relevant complication rates.

Total Vaginal NOTES Hysterectomy: A New Approach to Hysterectomy

The aim of this study was to demonstrate the feasibility of a total hysterectomy performed entirely by transvaginal natural orifice transluminal endoscopic surgery (vNOTES). Conventional, reusable laparoscopic instruments were used, inserted through an inexpensive, self-constructed single-port device. Ten total vaginal NOTES hysterectomies (TVNHs) were performed by a single surgeon. The self-constructed single-port device was made by assembling a surgical glove, a wound protector or modified laryngeal mask airway, 1 reusable 10-mm trocar, and 4 reusable 5-mm trocars. This gloveport was inserted into the vagina to create a pneumovagina. The conventional steps of a vaginal hysterectomy were followed, but performed endoscopically with standard reusable endoscopic instruments. The patient and perioperative data were analyzed. No conversion to standard laparoscopy or laparotomy was necessary in any of the 10 patients who underwent a TVNH. Mean operation time was 97 min (range: 60-120); mean drop in hemoglobin level was 1.5 g/dL (range: 0.5-2.4). There were no operative complications, and postoperative pain scores were very low. This first report on a small number of patients demonstrates that TVNH is possible. By incorporating the advantages of endoscopic surgery, TVNH broadens the indications for vaginal hysterectomy and helps overcome its limitations. At the same time, the NOTES approach avoids abdominal wall wounds and trocar-related complications. TVNH is feasible, even when performed with reusable, conventional laparoscopic instruments. This frugally innovative technique also enables surgeons to perform hysterectomies by vNOTES in low resource settings.

Clinical application of endoscopic thyroidectomy via an anterior chest wall approach

BACKGROUND

Endoscopic minimally invasive surgery of the cervical region is currently used to treat benign thyroid disease. The aim of this study was to evaluate the safety, feasibility, and inflammatory response to endoscopic thyroidectomy (ET) via an anterior chest wall approach.

METHODS

Between January 2007 and January 2012, 320 patients underwent sub-total/total thyroidectomy. Of these, 160 had endoscopic surgery through an anterior chest wall approach (ET, group A) and 160 had traditional open surgery (group B). Demographics, operation time, intraoperative blood loss, complications, hospital stay, cost, and postoperative outcomes were compared between the 2 groups. Serum Interleukin-6 and C-reactive protein levels were measured preoperatively and at 2, 12, 24, and 48 hours postoperatively.

RESULTS

Patient demographics, tumor size, operation time, and pathologic diagnoses were similar in both groups. There was no difference in procedure time and postoperative complication rates. Intraoperative blood loss and length of hospital stay were significantly lower in group A (P<0.05), but cost was higher (P<0.05). Serum Interleukin-6 and C-reactive protein levels increased significantly after both procedures, with levels at the 24-hour and 48-hour time points higher in group B (P<0.05). Two cases in group A and 1 in group B developed a transient hoarse voice postoperatively, which recovered 7.5 days (range, 5 to 12 d) later. There were no serious complications during the 2-year follow-up.

CONCLUSIONS

ET through an anterior chest wall approach is safe and feasible for benign thyroid disease, and offers the advantage of no visible scar.

To study the levels of C - reactive protein and total leucocyte count in patients operated of open and laparoscopic cholecystectomy

BACKGROUND

The recovery from laparoscopic cholecystectomy (LC) is rapid and most of the patients are discharged on the 1st post-operative day. There is an increased concentration of certain serum proteins, known as acute-phase reactive proteins (APRP) during the post-operative period depends on the degree of tissue damage and the inflammatory reaction. There is a direct positive correlation between the concentrations of APRP, especially C-reactive protein (CRP), and the severity of inflammation. This study was done to study the levels of C - reactive protein and Total Leucocyte Count in patients operated either by Open Cholecystectomy (OC) and Laparoscopic Cholecystectomy (LC).

MATERIALS AND METHODS

This prospective study was conducted on 50 patients after approval from the Institutional Ethics Committee. Twenty five patients underwent open cholecystectomy and the other 25 had laparoscopic cholecystectomy. The pre and post operative concentrations of serum C-reactive protein (CRP) and total leukocyte count (TLC) were compared in both the groups.

RESULTS

There were no differences in the preoperative serum CRP and TLC concentrations - in both the groups. Serum CRP rose significantly following OC compared to that of patients who underwent LC (10.52 ± 1.96 mg% vs. 8.88 ± 1.23 mg %). There were also significant differences in the post-operative TLC ( 9.49 ± 1.05 m/mm3 for the OC group vs. 8.57 ± 1.31 m/mm3 for the LC group), and the post-operative hospital stay (5.5 ±1.5 days vs. 1.9 ± 0.9 days). There was no correlation between serum CRP concentrations and the other post-operative parameters.

CONCLUSION

The study provided the biochemical evidence supporting the clinical observation that LC is far less traumatic to the patient than OC.

Perioperative advantages of modified laparoscopic vs open splenectomy and azygoportal disconnection

AIM: To investigate perioperative outcomes in patients undergoing modified laparoscopic splenectomy or open splenectomy and azygoportal disconnection for portal hypertension.

METHODS: This study included 44 patients who underwent modified laparoscopic splenectomy and azygoportal disconnection (MLSD) and 71 who underwent open procedures for portal hypertension. Blood samples were collected before surgery and on days 1, 3, and 7 after surgery. Markers of liver and renal function, C-reactive protein (CRP), interleukin-6 (IL-6), and procalcitonin (PCT) were measured, and perioperative variables were compared between the two groups.

RESULTS: The modified laparoscopic group showed significantly better and faster recovery, better liver and renal function, and fewer complications than the open group. CRP, IL-6, and PCT concentrations on postoperative days 1, 3, and 7 were significantly lower in the modified laparoscopic group than in the open group.

CONCLUSION: MLSD was associated with lower inflammatory immune responses, less impairment of liver and renal function, and faster and better recovery.

The effects of intraoperative esmolol administration on perioperative inflammatory responses in patients undergoing laparoscopic gastrectomy: a dose-response study

BACKGROUND

Surgical trauma elicits inflammatory responses, including the secretion of cytokines. Recent studies demonstrated that beta-blockers could reduce the expression of cytokines after injury. We therefore tested the effects of different doses of intraoperative esmolol on the inflammatory response after surgery.

METHODS

Patients undergoing laparoscopic gastrectomy were randomly separated into 1 of 3 groups: saline, clinical dose, and subclinical dose groups. The levels of interleukin (IL)-6, IL-4, and IL-10 were quantified by sandwich enzyme-linked immunoassay after the induction of anesthesia (T0), at the end of peritoneal closure (T1), and 60 minutes after surgery (T2). Levels of C-reactive protein (CRP) were measured on postoperative day 1.

RESULTS

At T2, the levels of IL-6 and IL-10 in the saline group were elevated significantly compared with at T0 or T1 (IL-6: 119.62 and 15.97 pg/mL at T2 and T0, respectively [P = .042]; IL-10: 27.27 and 7.03 pg/mL at T2 and T1, respectively [P = .037]). However, no changes were observed over time in the clinical dose group. In contrast, postoperative levels of IL-4 were decreased significantly in the clinical dose group compared with the saline group (2.14 vs 21.91 pg/mL, P = .022). In addition, the CRP levels on postoperative day 1 were lower in the esmolol-treated groups, in a dose-dependent manner.

CONCLUSIONS

Serum IL-6 and IL-10 levels were increased over time, suggesting that laparoscopic surgery is a stressor, even though it causes minimal tissue injury. Treatment with esmolol decreased the inflammatory response and CRP production in a dose-dependent manner.

Acute inflammatory response to transgastric natural orifice transluminal endoscopic surgery peritoneoscopy: an experimental study in swine

OBJECTIVE

To investigate the impact of transgastric peritoneal access on plasma biomarkers of acute inflammatory response in comparison to laparoscopy.

METHODS

This was a prospective and comparative study in a porcine model. Transgastric peritoneal access performed by natural orifice transluminal endoscopic surgery was compared with laparoscopy. Laparotomy and sham groups were used as positive and negative controls, respectively. Thirty-four pigs were assigned to receive transgastric natural orifice transluminal endoscopic surgery (n = 12), laparoscopy (n = 8), laparotomy (n = 8) or a sham procedure involving only anesthesia (n = 6). In the natural orifice transluminal endoscopic surgery group, peritoneoscopy was performed with a gastroscope via transgastric access. Blood samples were collected at baseline and 1, 3, 6, 9 and 24 h after the surgical procedure for measurement of interleukins 1β, 6 and 10 and tumor necrosis factor-α. A complete blood count was performed, and C-reactive protein levels were measured at baseline and at 24 h.

RESULTS

All surgical and endoscopic procedures were performed without major complications. Peritoneal cavity inventory showed no signs of peritonitis in any animal. Interleukin 1β, interleukin 10 and tumor necrosis factor-α levels were below the threshold of detection. The mean level of interleukin 6 was statistically significantly higher in the laparotomy group than in the other groups (p<0.05), with no significant differences among the sham, laparoscopy and natural orifice transluminal endoscopic surgery groups (p>0.05). C-reactive protein analysis indicated significant increases in all groups, with no differences among the groups. Complete blood count analysis showed no differences among the groups.

CONCLUSIONS

Based on the observed interleukin 6 patterns, the systemic inflammatory response resulting from transgastric peritoneal access by natural orifice transluminal endoscopic surgery is similar in intensity to the response that occurs after laparoscopy.

Effects of dexmedetomidine on inflammatory responses in patients undergoing laparoscopic cholecystectomy

BACKGROUND

Dexmedetomidine has been shown to reduce pro-inflammatory cytokine levels in rats with sepsis and in severely ill patients. The aim of this study was to document the effects of dexmedetomidine on inflammatory responses during and after surgery.

MATERIALS AND METHODS

Patients undergoing laparoscopic cholecystectomy were enrolled. After induction of anaesthesia, patients in the dexmedetomidine group (n = 24, group D) received a loading dose of dexmedetomidine (1.0 μg/kg), followed by infusion of dexmedetomidine at 0.5 μg/kg/h. A saline-treated group (n = 23, group S) served as a control. Intraoperative mean arterial pressure (MAP), heart rate (HR), and amount of rescue analgesic administered as post-anaesthetic care were compared between the groups. The pro-inflammatory cytokines tumour necrosis factor (TNF)-α, interleukin (IL)-1β, and IL-6, and anti-inflammatory cytokines IL-4 and IL-10 were quantified by sandwich enzyme-linked immunoassay at three times: after anaesthesia induction (T0), at the end of peritoneal closure (T1), and 60 min after surgery (T2). The C-reactive protein (CRP) level and leukocyte count were measured on post-operative day 1.

RESULTS

At time points T1 and T2, the IL-1β, TNF-α, and IL-10 levels were lower in group D than in group S (P < 0.05). The CRP level and leukocyte count on post-operative day 1 were also lower in group D (P < 0.05), as were intraoperative MAP, HR, and amount of rescue analgesic administered after surgery.

CONCLUSIONS

Dexmedetomidine administration during surgery reduced intraoperative and post-operative secretion of cytokines, as well as post-operative leukocyte count and CRP level.

Safety of culdotomy as a surgical approach: implications for natural orifice transluminal endoscopic surgery

OBJECTIVE

To evaluate the efficacy and safety of culdotomy as a surgical approach to access the peritoneal cavity and discuss its implications for natural orifice transluminal endoscopic surgery (NOTES).

METHODS

A retrospective chart review of women undergoing culdotomy for tubal sterilization (N 219) between January 1995 and December 2005 was performed. The Accordion Grading System was used for the severity of complications.

RESULTS

No intraoperative complications were noted. Postoperative complications occurred in 7 patients (3.2%): 6 infections (grade 2) and 1 case of hemorrhage (grade 3). Conversion to laparoscopy was necessary in 10 patients (2.2%) due to anatomical constraints or pelvic adhesions; however, culdotomy with entry into the abdominal cavity was nevertheless successful in all 10 cases. The difference in the proportion with a history of pelvic surgery between the conversion and nonconversion groups was not statistically significant (P = .068). Patients with BMI ≥30 had a higher conversion rate compared to patients with BMI <30 (11.4% versus 1.5%, P = .011). Tubal sterilization via culdotomy was successfully performed in all 11 women with no prior vaginal deliveries.

CONCLUSION

Culdotomy appears to be a safe surgical approach to access the peritoneal cavity and is associated with a low complication rate. These data support the feasibility and safety of utilizing the cul-de-sac as an access portal for natural orifice transluminal endoscopic surgery.

Blood cultures for evaluation of early postoperative fever after femoral neck fracture surgery

PURPOSE

To evaluate the utility of blood cultures in the assessment of early postoperative fever in hip fracture patients with no other indicators of sepsis.

METHODS

101 blood cultures were drawn on postoperative days 0 to 5 to investigate 84 febrile episodes in 31 women and 30 men (mean age, 80 years) whose body temperature measured via the tympanic route was ≥ 38 ºC. Culture results of these 61 patients were divided into culture-positive and culture-negative groups for comparison.

RESULTS

Of the 101 blood cultures, only 2 were positive: one was obtained 5 days after dynamic hip screw fixation, and the other 4 days after hemiarthroplasty. Both blood cultures grew coagulase-negative staphylococcal species, which were deemed to be skin contaminants not requiring change of patient management. 44 of these patients were treated with oral or intravenous antibiotics for a period of time.

CONCLUSION

The risk of bacteraemia in patients with postoperative fever but no other symptoms of infection is low. Routine procurement of blood cultures in such patients is ineffective and of limited utility.

Comparison of femoral and carotid blood pressure during laparoscopy in piglets

PURPOSE

The impact of a capnoperitoneum on the known blood pressure (BP) difference of the upper and lower limb was studied in piglets.

METHODS

Eleven German Landrace piglets (body weight, 4.3-7.4 kg; mean body weight, 6.2 kg) were studied. Arterial lines were placed in the right carotid and right femoral artery for pressure monitoring. Intraabdominal pressure levels were increased in steps of 6 mm Hg up to 24 mm Hg.

RESULTS

We found that elevated intraabdominal pressures up to 24 mm Hg did not change the preexisting systolic BP difference between the carotid and femoral arteries. Systolic femoral artery pressure constantly remained 5% higher than its carotid counterpart. In addition, mean and diastolic values were not affected.

CONCLUSIONS

Arterial BP measurements recorded at the legs of piglets when abdominal pressure is increased by up to 24 mm Hg can be used for intraoperative assessment of systemic arterial BP.

Effects of dexamethasone and pheniramine hydrogen maleate on stress response in patients undergoing elective laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) still leads to significant postoperative nausea and vomiting (PONV) and pain. Our aim was to evaluate the efficacy of dexamethasone or pheniramine hydrogen maleate, either alone or combined, in reducing the stress response and symptoms after LC.

METHODS

Patients were randomly assigned to 1 of 4 groups, each consisting of 20 patients: control, dexamethasone (8 mg/2 mL), pheniramine hydrogen maleate (45.5 mg/2 mL), and the combined group. The drugs were given before anesthesia induction.

RESULTS

C-reactive protein levels (CRP) and visual analog scale (VAS) scores were significantly less in the dexamethasone (P = .003) and combined groups (P < .001). Both dexamethasone (P < .001) and pheniramine hydrogen maleate (P = .005) significantly reduced PONV.

CONCLUSIONS

Dexamethasone significantly reduced postoperative pain and the systemic acute-phase response, whereas these effects were only partially attained with pheniramine hydrogen maleate. Both dexamethasone and pheniramine hydrogen maleate significantly reduced PONV. An additive effect seemed to occur if these drugs were used in combination.

What is the role of minimally invasive surgery in a fast track hip and knee replacement pathway?

INTRODUCTION

Minimally invasive hip and knee replacement surgery (MIS) continues to receive coverage in both the popular press and scientific literature. The cited benefits include a smaller scar, less soft tissue trauma, faster recovery, reduced hospital stay, decreased blood loss and reduced post-operative pain. These outcomes are highly desirable and consistent with the aims of fast track hip and knee pathways. This paper evaluates the literature and discusses whether performing MIS over conventional surgical techniques offers advantages in a fast track hip and knee pathway.

METHODS

An English language literature search was performed using the MEDLINE and PubMed databases. Case series, randomised controlled trials and systematic reviews were included in the review.

RESULTS

The reported improvements in recovery brought about by MIS must be considered multifactorial. In combination with improved clinical pathways, MIS can be associated with quicker recovery and shorter length of hospital stay.

CONCLUSIONS

There is insufficient evidence to indicate that surgical technique alone makes a significant difference to recovery or reduces soft tissue trauma. No consensus on whether to use MIS techniques in fast track hip and knee replacement pathways can therefore be drawn. This is especially important given that the complication rates of MIS in the low to medium volume surgeon appear unacceptably high compared with standard approaches. It is also too early to assess the long-term effects of MIS on implant survival.

C-reactive protein 2 days after laparoscopic gastric bypass surgery reliably indicates leaks and moderately predicts morbidity

BACKGROUND

The aim of the present study was to evaluate whether serum C-reactive protein (CRP) is a useful predictor of early post-operative complications, particularly of intestinal leaks after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery.

METHODS

The present study was a retrospective analysis of a prospectively maintained database with 809 patients who underwent LRYGB from 2002 until 2011. For 410 of these patients, at least one CRP measurement within the first seven post-operative days was available. The diagnostic value was determined by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve.

RESULTS

Forty-nine of 410 patients (12.0 %; 95 % confidence intervals [95 % CI], 9.2-15.5 %) developed surgery-related complications. Leaks occurred in 17 patients (4.1 %; 95 % CI, 2.6-6.5 %) at a median of 5 days after surgery. CRP levels 2 days after surgery showed the highest diagnostic value for post-operative complications (AUC, 0.74; 95 % CI, 0.60-0.89). Sensitivity was 0.53 (95 % CI, 0.31-0.74) and specificity was 0.91 (95 % CI, 0.79-0.96) on day 2 (cutoff level, 229 mg/l). The sensitivity for intestinal leaks was 1.00 (95 % CI, 0.51-1.00).

CONCLUSION

CRP on post-operative day 2 is a valuable predictor of post-operative complications, in particular intestinal leaks. Radiological imaging studies for intestinal leaks could be restricted to patients with CRP values exceeding 229 mg/l.

Systemic immunologic and inflammatory response after laparoscopic versus open nephrectomy: a prospective cohort trial

PURPOSE

To compare the dynamics of systemic inflammatory indices during laparoscopic nephrectomy (LN) and standard open donor nephrectomy.

PATIENTS AND METHODS

Participants in this cohort study were 54 adults without a history of renal surgery and no evidence of urinary tract infection who underwent transperitoneal LN (n=29) and open donor nephrectomy (n=25, control group). We recorded demographic characteristics, intraoperative parameters, and changes 24 hours postoperatively in systemic inflammatory and immunologic values (body temperature, concentrations of white blood cell count [WBC], C-reactive protein [CRP], interleukin [IL]-6, and tumor necrosis factor [TNF]-α), and compared the mean changes between groups.

RESULTS

Mean age was older in the LN group (45.6 vs 30.9 years; P<0.0001), and mean operative time was significantly shorter (83.1 min vs 101.6 min; P=0.004). Mean postoperative increase in IL-6 and body temperature in LN was significantly less than in control: For IL-6, 15.87 vs 29.09 pg/mL, P=0.03; for body temperature, +0.22°C vs +0.71°C, P=0.001). Mean postoperative increases in levels of other inflammatory markers (CRP, TNF-α, WBC) did not differ significantly. No statistical correlation was found between operative time and changes in IL-6, CRP, TNF-α, WBC, or body temperature.

CONCLUSION

Based on the smaller increase in serum IL-6 as the most important indicator of surgical stress, the surgical trauma-induced immune dysfunction may be less intense after LN than open surgery. This may explain the smooth convalescence after LN.

Circulating cytokines in patients undergoing tonsillectomy with fibrin glue

OBJECTIVE

Fibrin glue is used as a haemostatic agent or as a sealant. The aim of this study is to objectively evaluate the efficacy of the use of fibrin glue Quixil - a human surgical sealer - in tonsillectomy, for the reduction of post-operative inflammatory response.

STUDY DESIGN

A prospective randomized single-blind study.

METHODS

The study was performed on 40 consecutive patients undergoing adenotonsillectomy (T&A). Patients were randomly assigned to one of two sub-groups: a study group and a control group. The tonsillar beds of patients in the study group were coated with fibrin glue (Quixil, OMRIX biopharmaceuticals) at the end of the operation; the patients in the control group were treated for hemostasis without the use of fibrin glue. Complete blood counts and circulating pro-inflammatory cytokines (assayed by specific immunoassay - ELISA) were assessed in samples drawn pre- and 16 h post-tonsillectomy.

RESULTS

Forty patients (aged 5.8 ± 2.4 years) were consecutively enrolled; 45% (18) of the patients were treated with fibrin glue, 55% (22) were not. Compared to controls, Quixil-treated patients demonstrated a reduction in post-tonsillectomy circulating leukocytes (29.2% vs. 45.4%, p<0.05), neutrophiles (28.3% vs. 42.1%, p<0.05), IL-6 (+1% vs. +42%, p<0.05), and TNF-alpha (+8% vs. +26%, p<0.05.

CONCLUSIONS

Intra-operative fibrin glue therapy is associated with decreased immediate inflammatory response following T&A. Further studies are warranted to assess long-term outcome.

LEVEL OF EVIDENCE

1B.